Examination of gynecological patients lecture. Examination methods in gynecology. General and special methods for examining gynecological patients

Modern methods of objective examination of gynecological patients include,

Examination methods in gynecology

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

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

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Anamnesis

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

Taking into account the hereditary nature of many diseases, information should be obtained about mental illness, endocrine disorders (diabetes, hyper- or hypothyroidism, etc.), the presence of tumors (fibroids, cancer, etc.), and pathology of the cardiovascular system in relatives of the first and second generations. In addition to the usual questions regarding family history, in women with menstrual irregularities, infertility, excess hair growth, it is necessary to find out whether immediate relatives have obesity, hirsutism, or whether there have been cases of miscarriage.

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

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

Menstruation disorders most often occur due to dysfunction nerve centers regulating the activity of the endocrine glands. The functional instability of this system can be congenital or acquired as a result of damaging factors (diseases, stressful situations, malnutrition, etc.) in childhood and during puberty.

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

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

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

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

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

Assessment of general condition

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

It is necessary to examine the area of ​​lymph nodes accessible to palpation. Measurement of blood pressure, pulse rate, listening to the lungs, percussion and palpation of the abdomen are carried out. The mammary glands are carefully examined, a visual inspection is carried out in a standing position, then sequential palpation is carried out in a lying position armpits, external and internal quadrants of the gland.

Gynecological examination

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

Examination of the external genitalia.

Pay attention to the nature and degree of hair growth, the development of the labia minora and majora, and the gaping of the genital slit. During examination, the presence of inflammatory pathological processes, ulcers, tumors, varicose veins, and discharge from the vagina or rectum is noted. The woman is asked to push, while determining whether there is prolapse or prolapse of the walls of the vagina and uterus.

Inspection using a mirrorcal.

The examination is carried out before a vaginal bimanual (two-handed) examination, since the latter can change the picture of the pathological process. Casement or spoon-shaped mirrors are used. The folding speculum is carefully inserted in a closed state along the entire length of the vagina, after first spreading the labia minora with the left hand. If a spoon-shaped speculum is used, then an additional lift is inserted to lift the anterior wall of the vagina. Having exposed the cervix, they examine it, noting the color of the mucous membrane, the nature of the secretion, the shape of the cervix, the presence of ulcers, scars, polyps, tumors, fistulas, etc. After visual inspection smears are taken for bacterioscopic and cytological examination.

Vaginal (bimanual) examination.

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

Vaginal examination data allows you to diagnose the presence of uterine tumors, fallopian tube formations and ovarian tumors. We must not forget that for correct diagnosis it is important not so much the presence of individual symptoms as their detection in combination with other signs of the disease.

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

Bacterioscopic examination.

It is used to diagnose inflammatory diseases, and its results allow us to determine the type of pathogen. Bacterioscopy makes it possible to determine the degree of cleanliness of the vagina, which is necessary before any diagnostic procedures and gynecological operations. Material for bacterioscopic examination is taken with a Volkmann spoon from the urethra, cervical canal, and posterior vaginal fornix. Before the study, you should not treat the vaginal walls with disinfectants, douche or inject medications. It is better to take a smear before urinating. A smear is taken from the urethra using a Volkmann spoon with a narrow end or a grooved probe after preliminary massage of the urethra from back to front, pressing the urethra to the womb until a drop of discharge is obtained, which is applied to a glass slide with markings in a thin layer. A smear from the cervical canal is taken after exposing the cervix in the speculum using a Volkmann spoon with a wide end or a probe. Each smear is taken with a separate instrument, applied in a thin layer to two glass slides. According to the nature of the smear, there are four degrees of purity of vaginal contents:

I degree of purity. The smear reveals single leukocytes (no more than 5 in the field of view), vaginal bacilli (Dederlein bacilli) and squamous epithelium. The reaction is sour.

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

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

IV degree of purity. There are no vaginal bacilli, many pathogenic microbes, including specific ones - gonococci, trichomonas, etc. The reaction is alkaline.

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

Cytological examination.

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

Colposcopy.

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

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

Probing of the uterus.

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

Curettage of the uterine cavity.

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

Cervical biopsy.

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

Puncture through the posterior vaginal fornix.

It is widespread and effective method a study that can be used with a high degree of confidence to confirm the presence of intra-abdominal bleeding, as well as to analyze the discharge obtained by puncture.

Ultrasound examination (ultrasound).

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

Hysteroscopy (HS).

The main advantage of the method is the ability to detect intrauterine pathology using the optical system of a hysteroscope. Gas and liquid hysteroscopy are used. With gas HS, the uterine cavity is examined in a gas environment (carbon dioxide). The most commonly used liquid HS using various solutions, most often isotonic solution sodium chloride. The great advantage of this method is the ability to perform not only an examination of the uterine cavity, but also surgical procedures with subsequent monitoring (diagnostic curettage, polypectomy, “unscrewing” of the myomatous node, separation of synechiae, etc.). Expansion of the cervical canal to № 8-9 Hegara dilators guarantee the free outflow of lavage fluid and prevent pieces of the endometrium from entering the abdominal cavity. Indications for hysteroscopy:

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

Hysterosalpingography (HSG).

HSG has long been used in gynecology to determine the patency of the fallopian tubes, detect anatomical changes in the uterine cavity, and adhesions in the pelvic cavity. HSG is performed in an X-ray operating room. The study is performed with aqueous, contrast agents (Verografin - 76%, Urografin - 76%, Urotrast - 76%). The solution is injected into the uterine cavity under aseptic conditions using a special guide with a tip, after which an x-ray is taken.

Laparoscopy.

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

Computed tomography (CT).

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

Magnetic resonance imaging (MRI).

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

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

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

General objective examination

An objective examination begins with a general examination. In this case, it is important to pay attention to the color of the skin and mucous membranes (pallor, cyanosis, jaundice, pigmentation), the presence of edema, forced position, compliance with the general appearance age of the patient, excess or insufficient hair growth, height and body weight, constitutional features, obesity or exhaustion. Pale skin is characteristic of diseases accompanied by blood loss (fibroids, tubal pregnancy). Emaciation and sallow complexion are typical for malignant neoplasms. Excessive hair growth and obesity are possible with disorders of menstrual function of endocrine etiology. You should pay attention to pathological skin rashes and hemorrhages. Height and physique characterize the constitution of the patient. In gynecological patients, infantile, intersex and asthenic types should be distinguished, the presence of which may be associated with impaired sexual development and sexual differentiation.

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

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

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

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

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

When examining the respiratory, circulatory, digestive and urinary systems, inspection, percussion, palpation, and auscultation are performed. Detection common diseases will help clarify the etiology of the gynecological disease. For example, with pulmonary tuberculosis or another localization, tuberculosis of the uterine appendages can be suspected. Changes in frequency, pulse tension, and decreased blood pressure can accompany gynecological diseases accompanied by acute blood loss and shock.

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

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

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

Auscultation of the abdomen is also important in the diagnosis of gynecological diseases, especially when performing differential diagnosis tumors and pregnancy (fetal heartbeat is heard). With pelvioperitonitis, peritonitis, postoperative intestinal paresis, intestinal motility is sluggish or absent. When intestinal volvulus occurs, violent peristalsis is possible. Study nervous systems We are limited to determining the adequacy of the patient’s behavior and her orientation in time and space. What matters is the presence of increased irritability, tearfulness, and sleep disorders, which often accompanies gynecological diseases, especially those with a chronic course. If necessary, consult a neurologist who conducts a special neurological examination.

Each identified symptom must be assessed in conjunction with the others.

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

Gynecological examination

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

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

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

These include:

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

Examination of the external genitalia. A gynecological examination of the patient is carried out after emptying the bladder (if it is impossible to urinate independently, urine is removed with a catheter) and preferably after defecation with the patient lying on the gynecological chair on her back with her knees bent and hip joints feet. The examination is carried out using sterile rubber gloves, preferably disposable.

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

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

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

Having exposed the cervix, they examine it, characterizing its shape, the presence of scars, ulcers, polyps, fistulas, marks from bullet forceps, etc. A conical cervix with a pinpoint pharynx is found in nulliparous women. Cicatricial deformation indicates ruptures during childbirth. Hypertrophy of the cervix may indicate chronic inflammation.

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

There may be polyps and tumors (cancer, submucous fibroids) in the external pharynx. It is necessary to note the nature of the discharge (purulent, bloody). When removing the speculum, it is necessary to examine the walls of the vagina to exclude pathological changes(fistulas, hyperemia).

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

Softening of the cervix may be characteristic of pregnancy, hardening may be characteristic of inflammation or tumors. Immobility of the cervix is ​​observed when the surrounding tissue is damaged by a tumor or inflammatory infiltrate, excessive mobility of the cervix is ​​observed when the uterus prolapses. Pain when the cervix is ​​displaced is characteristic of inflammation of the uterine appendages and pelvic peritoneum, and of interrupted tubal pregnancy. The external pharynx can be slightly opened when there is cicatricial deformation of the cervix, as well as when an abortion has begun or is incomplete.

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

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

If tumor-like formations are identified in the area of ​​the appendages, it is necessary to characterize their size, shape, consistency, size, surface, mobility and sensitivity. When identifying clearly defined, rounded tumor-like formations, the presence of a cyst or tumor can be assumed. Lumpiness, dense consistency, and limited mobility are characteristic of malignant tumors.

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

Pathological processes in the pelvic tissue are determined in the form of dense, motionless infiltrates, often displacing the uterus in the opposite direction.

With a two-handed examination, the uterosacral ligaments can be palpated, especially if they are affected by endometriosis.

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

Rectal examination is carried out with one finger, while determining the condition of the ampulla of the rectum, cervix, uterosacral ligaments, and pelvic tissue.

During a rectovaginal examination, the second finger is inserted into the vagina, and the third finger into the rectum in the presence of a pathological process in the rectovaginal septum, vaginal wall, or intestine (endometriosis, uterine cancer). Using the external hand (rectoabdominal examination), the body of the uterus and appendages are palpated (Fig. 13).

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

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

The idea of ​​patient-doctor collaboration is gaining increasing recognition. The patient can participate in decisions regarding her health. Written consent should be obtained from the patient for various manipulations and operations.

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

17

Anamnesis

History collection scheme

1. Complaints: main, related.

2. History of the present illness.

3. Life history.

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

5. Gynecological diseases, genital surgeries.

6. Features of contraception.

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

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

Objective examination

Upon examination, they determine body type:

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

With the infantile type, both general (universal) infantilism and sexual (genital) infantilism without common features underdevelopment. The infantile type is characterized by short stature, underdevelopment of the mammary glands, and a uniformly narrowed pelvis. Menarche often occurs later than usual, and menstruation is characterized by irregularity and pain.

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

18 Practical gynecology

systems Women of the asthenic type experience relaxation of the muscular and connective tissue apparatus of the pelvic floor and perineum, and often increased, lengthened and painful menstruation.

The intersex type is characterized by insufficient differentiation of sex, especially secondary sexual characteristics. This type of woman has physical and mental signs characteristic of male body. In women of the intersex type, the hairline is highly developed, often in a male pattern, facial features resemble those of a man, and the genitals are often hypoplastic.

Between these basic types of constitution, there are various transitional options, which are characterized by combinations of individual characteristics characteristic of different body types.

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

Condition of the mammary glands:

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

Ma 1 - swelling of the isola, increase in its diameter, pigmentation of the nipple is not expressed;

Ma 2 - the mammary gland is conical in shape, the isola is pigmented, the nipple is raised;

Ma 3 - mature breasts of a round shape.

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

Examination of the breast is carried out in a standing and lying position, followed by palpation of the outer and inner quadrants of the gland. During the examination, attention is paid to changes in the volume and shape of the breast, as well as changes in the color of the skin, nipple and isola, the presence or absence of discharge from the nipples, their color, consistency, character. Brown nipple discharge or blood indicates a possible malignant process or papillary lesions.

Chapter 1. Methods of examination of gynecological patients 19

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

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

Assessment of body weight, height, body proportionality.

Body Mass Index (BMI)- the ratio of body mass to the square of body length.

Normal BMI = 20-26

BMI 26-30 - low probability of metabolic disorders;

BMI 30-40 - average degree the likelihood of their development (grade III obesity);

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

In case of excess body weight, they find out when obesity began: from childhood, at puberty, after the onset of sexual activity, after abortion or childbirth.

Abdominal examination carried out with the patient lying on her back. Pay attention to its configuration, swelling, symmetry, participation in the act of breathing, the presence free liquid in the abdominal cavity.

By palpation, the size of individual organs is determined, ascites, flatulence, and space-occupying formations are excluded. The size of the liver is determined. Then the remaining abdominal organs are palpated.

Abdominal examination provides valuable information. For example, if a patient with a pelvic tumor has a mass formation in the epigastric or umbilical region, ovarian cancer with metastases to the greater omentum should be excluded.

20 Practical gynecology

Gynecological examination carried out on a gynecological chair.

Examination of the external genitalia

Examine the pubis, labia majora and minora, perineum, anus. The condition of the skin, the nature of hair growth, and the presence of space-occupying formations are noted. All suspicious areas are palpated.

Using the index and middle finger of a gloved hand, spread the labia majora and inspect the anatomical structures in order: labia minora, clitoris, external opening of the urethra, entrance to the vagina, hymen, perineum, anus.

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

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

Examination of the vagina and cervix in speculums

When examining the vagina, note the presence of blood, the nature of the discharge, anatomical changes (congenital and acquired); condition of the mucous membrane; pay attention to the presence of inflammation, space-occupying lesions, vascular pathology, trauma, and endometriosis. When examining the cervix, pay attention to the same changes as when examining the vagina. But at the same time, you need to keep in mind the following: if there is bloody discharge from the external uterine pharynx outside of menstruation, a malignant tumor of the cervix or body of the uterus is excluded; with cervicitis, mucous- purulent discharge from

Chapter 1. Methods of examination of gynecological patients 21

external uterine os, hyperemia and sometimes erosion of the cervix; Cervical cancer cannot always be distinguished from cervicitis or dysplasia, therefore, at the slightest suspicion of a malignant tumor, a biopsy is indicated.

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

The walls of the vagina and its vaults are palpated. When palpating the cervix, its position, shape, consistency, pain and mobility are assessed. The presence of space-occupying formations and anatomical changes is noted.

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

Currently, clinical, laboratory, instrumental, and endoscopic research methods are used to diagnose gynecological diseases, which allow the doctor to determine the state of the female body and identify disorders leading to disorder of the woman’s health.

Taking a history of a gynecological patient

The examination of a gynecological patient begins with anamnesis. Its purpose is to identify the main complaints, obtain information about previous life and previous diseases, and the development of this disease.

Survey carried out in a certain sequence. First, they find out general information: last name, first name, patronymic, marital status, profession, age, living and nutritional conditions, bad habits of the patient.

Age is important, since the same symptom in different periods A woman’s life can be a manifestation of various diseases.

Finding out the patient’s profession and working conditions helps clarify the causes of many pathological processes. For example, work associated with prolonged cooling or overheating can lead to an exacerbation of the inflammatory process.

After receiving general information the patient should be asked about the complaints that forced her to see a doctor. Complaints upon admission are clarified without excessive detail, since in the future they are clarified by identifying the characteristics of the specific functions of the female body (menstrual, sexual, reproductive and secretory) and the history of the present disease.

Typically, gynecological patients complain of pain, leucorrhoea, menstrual cycle disorders (usually uterine bleeding), and infertility. Pain is a symptom accompanying many gynecological diseases. They vary in intensity, localization, character (constant, aching, cramping, gnawing), and irradiation.

When collecting anamnesis, attention should be paid to heredity. Presence of parents or close relatives chronic infections(tuberculosis, etc.), mental, venereal, tumor diseases, blood diseases helps to determine the patient’s predisposition to these diseases.

The patient's interview includes finding out her life history, starting from an early age. Of particular importance in identifying the causes of gynecological diseases are common diseases in past. Frequent sore throats, rheumatism, liver diseases, neuroinfections and other diseases often lead to menstrual dysfunction and retardation in physical and sexual development.

Obstetric and gynecological history includes information about the features of specific functions of the female body: menstrual, sexual, reproductive and secretory.

The survey should begin with finding out the time of the first menstruation (menarche), the type of menstrual function (duration of the menstrual cycle and menstruation, the amount of blood lost, pain), and the date of the last menstruation.

Peculiarities of sexual function are closely related to gynecological diseases: the onset of sexual activity, sexual sensation, sexual intercourse disorders (pain, the appearance of bloody discharge after sexual intercourse), methods of preventing pregnancy (contraception). The age and health status of the husband may play a role in establishing the diagnosis. When clarifying the nature of childbearing function, information is carefully collected on the number of pregnancies, their course and outcome. If the patient complains of infertility, you should find out what studies and treatment were previously carried out.

The nature of the secretory function is determined by obtaining data on the presence of pathological discharge (leucorrhoea) from the genital tract and its quantity. The causes of leucorrhoea are most often inflammatory diseases of the vulva, vagina, cervix and overlying organs of the reproductive system of various etiologies. In addition to inflammatory diseases, leucorrhoea can be a sign of polyp and uterine cancer. They can be thick, liquid, watery, purulent, ichorous, and sometimes cause itching in the area of ​​the external genitalia and vagina.

Often a symptom of a gynecological disease is dysfunction of the urinary tract and intestines. Therefore, when interviewing the patient, it is necessary to inquire about the condition of these adjacent organs. Information about previous gynecological diseases, their course, outcome, treatment, including surgical interventions, should be clarified in detail.

After establishing the characteristics of the obstetric and gynecological history, they proceed to history of the present illness. Particular attention is paid to information about the development of the present disease: the time of occurrence, connections with abortion, childbirth, menstruation and other factors, the nature of the treatment and its results. After the interview, the doctor has sufficient information to make a preliminary conclusion about the nature of the disease. To further clarify the diagnosis, an objective examination of the patient is necessary.

Objective research methods in gynecology

General research allows you to get an idea of ​​the state of the body as a whole. It includes a general examination (body type, condition of the skin and mucous membranes, nature of hair growth, condition and degree of development of the mammary glands), examination of organs and systems using generally accepted medical methods.

Particular attention is paid to examining the patient’s abdomen. In addition to examination, methods of palpation, percussion and ascultation of the abdomen are used, which often give rise to the assumption of a gynecological disease. Further general research the patient consists of measuring body temperature, blood pressure, as well as laboratory testing of blood, urine, feces, etc.

Special research methods Gynecological patients are numerous and vary in purpose and degree of complexity.

A gynecological examination of the patient is carried out in a horizontal position on a gynecological chair or hard couch. The head end of the chair must be raised, the legs bent at the knees and widely spread to the sides are held in place by leg holders. A woman must be previously prepared for a gynecological examination. If she does not have stool, a cleansing enema is given in advance.

Immediately before the examination, she should empty her bladder, and if spontaneous urination is delayed, the nurse, as prescribed by the doctor, removes urine using a catheter. For examination, the nurse must prepare sterile instruments: vaginal speculum, tweezers, forceps, probes, as well as glass slides for taking smears, sterile cotton balls and gauze napkins. Examination of gynecological patients is carried out wearing sterile rubber gloves.

Gynecological examination begins with examination of the external genitalia, in which attention is paid to the type of hair growth, the structure of the labia majora and minora, the condition of the external opening of the urethra, the excretory ducts of the paraurethral and large glands of the vestibule, perineum and anus. To examine the vestibule of the vagina, spread the labia with the thumb and index fingers of the left hand. Pay attention to the gaping of the genital slit. The presence of prolapse or prolapse of the walls of the vagina and uterus is determined when the patient strains.

Research using mirrors performed after examination of the external genitalia. There are various models of vaginal speculum, among which the most commonly used are bicuspid self-supporting and spoon-shaped speculums. The use of a double-leaf mirror does not require an assistant, so it is used more often in outpatient practice.

The nurse should know the rules for inserting a speculum. Before inserting the speculum, the labia are parted with the index and thumb left hand. The double-leaf speculum is inserted closed in straight size to the middle of the vagina. Next, the mirror is turned to a transverse size and advanced to the fornix, opening the valves, as a result of which the cervix becomes accessible for inspection. The spoon-shaped speculum is first inserted with its edge along the posterior wall of the vagina, and then, having been inserted into the depths, it is turned across, pushing the perineum backwards.

In parallel, an anterior speculum-lift is inserted, which is used to lift the anterior wall of the vagina. When examining with mirrors, the shape of the cervix is ​​determined (conical in a nulliparous woman, cylindrical in a woman who has given birth, deformed), its position, size, color of the mucous membrane, and the presence of pathological processes. The walls of the vagina are examined by gradually removing the speculum.

Vaginal (internal examination) performed after examination using mirrors with the index and middle fingers or only index finger one hand (usually the right). A vaginal examination allows you to determine the condition of the perineum, pelvic floor muscles, urethra, large glands of the vestibule, vaginal walls and the vaginal part of the cervix.

Rice. 69. Two-handed (vaginal-abdominal) examination

Two-manual vaginal (bimanual, vaginal-abdominal) examination is the main method for diagnosing diseases of the uterus, appendages, pelvic peritoneum and tissue (Fig. 69). It is carried out in a certain sequence. First of all, the uterus is examined, determining its position, size, shape, consistency, mobility, and pain.

During a two-handed examination, the uterus moves within certain limits up, down, anteriorly and to the sides, but then returns to its original position, which determines the physiological nature of this mobility. Then they begin to examine the uterine appendages. To do this, the fingers of both hands (outside and inside) are gradually moved from the corners of the uterus to the side walls of the pelvis. Unchanged fallopian tubes are usually not palpable, and the ovaries can be palpated in the form of small ovoid formations. A two-handed examination also makes it possible to identify pathological processes in the area of ​​the pelvic peritoneum and the tissue of the pelvic ligaments.

Rectal and rectal-abdominal examination used in virgins, with atresia or stenosis of the vagina, as well as with inflammatory or tumor processes in the reproductive system. The examination is carried out wearing a rubber glove with a fingertip, which is lubricated with Vaseline.

Rectal-vaginal examination is used for diseases of the posterior wall of the vagina or the anterior wall of the rectum. In this case, the index finger is inserted into the vagina, and the middle finger of the right hand is inserted into the rectum.

Additional research methods in gynecology

All women admitted to the gynecological hospital are subjected to bacterioscopic examination. Discharges from the lower parts of the genitourinary system - vagina, cervical canal and urethra - are subject to examination. A nurse working in a hospital or antenatal clinic must master the technique of correctly taking smears. First of all, the nurse should warn the patient that on the eve and on the day of taking smears she should not have sexual intercourse or douche.

She should also not urinate for 2 hours before taking swabs. The nurse needs to prepare two glass slides, well washed, wiped with alcohol or ether and dried. Using a special pencil, each glass is divided into three parts, on one of which the letter U is written, which means urethra, on the second C - cervix, on the third V - vagina.

When taking material from various parts of a woman’s genital organs, the nurse should: remember the need to carefully observe the rules of asepsis and antisepsis. Only sterile instruments are used, and the same instrument cannot be used to take smears from different places. Smears are taken before a gynecological examination of the patient, as well as before vaginal medical procedures.

To obtain smears, the woman is placed on a gynecological chair. First, swabs are taken from the urethra; To do this, gently massage it with a finger inserted into the vagina. The first portion of discharge from the urethra should be removed with a cotton ball and then injected into urethra(to a depth of no more than 1.5-2 cm) a grooved probe, the tip of tweezers or a special spoon (Volkmann). The material from the urethra is obtained by lightly scraping and applied in the form of a circle on two glass slides with a U mark.

After taking smears, a sterile speculum is inserted from the urethra into the vagina, the cervix is ​​exposed, and after wiping it with a cotton ball with a sterile instrument, a smear is taken from the cervical canal in the same way as from the urethra. Light scraping is necessary so that the test material gets gonococci, which are usually located not on the surface of the mucous membrane, but under the epithelial cover. Next, the discharge is taken from the posterior vaginal fornix with tweezers or a forceps.

Discharge from the cervix and vagina is applied separately as a streak onto glass slides with the appropriate mark. The smears are dried and then sent with an accompanying note to the laboratory. In the laboratory, smears are stained with methylene blue on one slide, and Gram stained on the second, after which they are subjected to microscopic examination. During bacterioscopic examination of smears from the posterior vaginal fornix, the degree of purity of the vaginal contents is determined. Smears from the urethra and cervical canal are used for bacterioscopic examination for gonococci and flora.

If necessary, the secretion of the vestibular glands and rectum can be subjected to bacterioscopic examination. Patients who are suspected of having gonorrhea undergo a so-called provocation. Under provocation understand special measures of influence on a woman’s body, aimed at exacerbating the inflammatory process of gonorrheal origin in order to facilitate bacterioscopic diagnosis of the disease. There are physiological, biological, thermal, mechanical and nutritional provocations.

A physiological provocation is menstruation, therefore, when using this method, smears from the urethra and cervical canal are recommended to be taken on the 2-4th day of menstruation.

Of the numerous methods of artificially activating the inflammatory process, the following are most often used:

1) intramuscular injection gonovaccines(500 million or more microbial bodies);

2) lubricating the mucous membrane of the cervical canal and urethra Lugol's solution on glycerin or silver nitrate solution(for the urethra - 0.5% solution, for the cervix - 2-3% solution);

3) physiotherapeutic procedures (inductothermy, zinc electrophoresis using a cervical or vaginal electrode, ultrasound, therapeutic mud).

Currently, pyrogenic drugs are widely used to provoke gonorrhea. (pyrogenal). After these provocation methods, it is necessary to take smears after 24, 48, 72 hours.

In a number of patients, in order to identify the latent form of gonorrhea, to determine the biological properties of the flora and determine sensitivity to antibiotics, as well as to identify tubercle bacilli if a specific inflammatory process in the genitals is suspected, it is used bacteriological examination method of cultures, i.e. sowing secretions from various parts of the reproductive system on artificial nutrient media. Taking material for bacteriological research is carried out with a sterile swab on a wire, which is slowly placed in a sterile tube and sent to the laboratory.

In clinical outpatient practice for the purpose of early diagnosis of genital cancer, it is widely used cytological method research. For cytological examination of the cervix, smears should be taken from the surface of the vaginal part and from the cervical canal. The material can be obtained using anatomical tweezers, a Volkmann spoon, a grooved probe or a special metal spatula with a notch at the end. Smears from the uterine cavity are obtained by aspiration with a syringe having a long tip (Brown syringe). The resulting smears from various parts of the reproductive system are applied to glass slides, fixed in a mixture of alcohol and ether, stained and examined under a microscope to identify atypical cellular complexes.

Functional diagnostic tests.

Tests assess the hormonal function of the ovaries. The nurse should be familiar with the most simple and accessible functional diagnostic tests.

Cervical mucus examination based on changes in the physicochemical properties of mucus during the menstrual cycle. Its amount increases from 60-90 mg/day in the early follicular phase to 600-700 mg/day during the period of ovulation; By the same period, the activity of some mucus enzymes increases and its viscosity decreases. The “pupil” and “fern” phenomena are based on changes in the secretion and refractive power of cervical mucus.

Symptom (phenomenon) of “pupil” allows us to judge the production of estrogen by the ovaries. From the 8-9th day of the two-phase menstrual cycle, the external opening of the cervical canal begins to expand, reaching a maximum at the time of ovulation; glassy transparent mucus appears in it. When directed by a beam of light, the external pharynx with a protruding drop of mucus appears dark and resembles a pupil. In the second phase of the cycle, the external os of the cervix begins to gradually close, the amount of mucus decreases significantly, the symptom disappears by the 20-23rd day of the menstrual cycle. The test is not typical for cervical erosion, endocervicitis, or old cervical ruptures.

Fern symptom (arborization test) based on the ability of cervical mucus to form crystals when dried.

The material is taken from the cervical canal with anatomical tweezers at a depth of 0.5 cm; a drop of mucus is dried and the result is assessed under a microscope at low magnification.

The test is used to diagnose ovulation. The presence of the “fern” symptom throughout the entire menstrual cycle indicates high secretion of estrogen and the absence of the luteal phase; its lack of expression during the examination may indicate estrogen insufficiency.

Symptom of cervical mucus tension also allows us to judge the production of estrogen by the ovaries. Its maximum severity coincides with ovulation - mucus from the cervical canal, taken with tweezers, is stretched by the jaws by 10-12 cm.

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

In vaginal smears, four types of cells are distinguished - basal, parabasal, intermediate and superficial:

I reaction: the smear consists of basal cells and leukocytes; the picture is typical for severe estrogen deficiency;

II reaction: the smear consists of parabasal, several basal and intermediate cells; the picture is typical for estrogen deficiency;

III reaction: in the smear there are mainly intermediate cells, there are single parabasal and superficial ones; the picture is characteristic of normal estrogen production.

IV reaction: superficial cells and a small amount of intermediate cells are detected in the smear; The picture is typical for high estrogen production.

The quantitative ratio of cells in a smear and morphological characteristics are the basis of hormonal cytological diagnosis. Material for research is taken from the lateral fornix upper third vagina (the most sensitive to hormonal effects), without rough manipulation, since the cells that are separated from the vaginal wall are subject to examination.

To interpret the test, the following indices are calculated:

- maturation index (MI)- percentage ratio of superficial, intermediate and parabasal cells. Written as three consecutive numbers, for example: 2/90/8;

- karyopyknotic index (KI, KPI)- percentage of superficial cells with a pyknotic nucleus to superficial cells with nuclei.

During the ovulation menstrual cycle, the following fluctuations in CI (CI) are observed: in the first phase 25-30%, during ovulation 60-80%, in the middle of the second phase 25-30%.

It is assumed that there are three options for the penetration of microbes from the lower parts of the genital tract to the upper: with Trichomonas, with sperm, and passive transport due to the suction effect of the abdominal cavity. Exacerbation of the chronic inflammatory process is often caused by such unfavorable factors as hypothermia or overheating of the body, excessive physical or mental stress, stressful situations, occupational exposure, as well as general diseases.

Clinical manifestations of pelvic inflammatory diseases and the tactics of therapeutic approaches to them depend not only on the nature of the infectious agent: the woman’s age and previous health status, possible invasive diagnostic, therapeutic and other interventions on the genital apparatus, but also on the location of the lesion.

Depending on the localization of the process, inflammation of the external genitalia (vulvitis, bartholinitis), vagina (colpitis), uterus (endocervicitis, cervicitis, cervical erosion, endometritis), uterine appendages (salpingoophoritis), pelvic tissue (parametritis), pelvic peritoneum (pelvioperitonitis) and diffuse inflammation of the peritoneum (peritonitis).

The most common symptoms of acute inflammation of the female genital organs are local pain, leucorrhoea, swelling of the affected organ, as well as often an increase in body temperature and a change in the blood picture characteristic of the inflammatory process (leukocytosis, increased ESR). Sometimes menstrual function is disrupted.

In subacute inflammation, the pain is moderate, the body temperature is not higher than subfebrile, and there are little or no changes in the blood picture. In chronic inflammation, the appearance of an acute process is regarded as an exacerbation.

In the chronic stage of the inflammatory process in the affected organ, changes in nerve receptors and capillaries, proliferation connective tissue with the formation of adhesions, as well as a change in the general immunological reactivity of the body.

Nonspecific inflammatory diseases female genital organs arise under the influence of the so-called pyogenic flora (staphylococci, E. coli, etc.).

Rarely, the cause of nonspecific inflammatory diseases may not be microbial, but mechanical, thermal and chemical agents. Usually the disease is preceded by some kind of surgical intervention (artificial abortion, diagnostic curettage of the mucous membrane of the uterine body, biopsy) as a result of which an entrance gate for infection is formed. Poor hygiene of the genital organs and sexual life, inflammatory diseases of the urinary system and intestines are also a source of inflammatory diseases of the female genital organs.

Vulvitis- inflammation of the external genitalia. With this disease, patients complain of burning, pain, and often itching in the area of ​​the labia and vaginal opening. When examining the external genitalia, hyperemia and swelling of the tissues, purulent discharge, and possible ulcerations are noted.

For successful treatment vulvitis, it is necessary to find out the reasons that predispose to this disease (hypofunction of the ovaries, diabetes mellitus, helminthiasis, non-compliance with personal hygiene rules, masturbation, etc.) and eliminate them. Local treatment consists of hygienic treatment of the genitals with various disinfectant solutions (potassium permanganate in a ratio of 1:10,000, 2% boric acid solution, chamomile infusion, etc.), followed by lubrication with synthomycin liniment or streptocidal emulsion, ointments with vitamins, estrogens. Sitz baths made from infusions of chamomile, potassium permanganate, St. John's wort, and string are also recommended.

Bartholinitis is inflammation of the large vestibular gland. It is characterized by sharp pain, swelling and infiltration in the labia majora area. During the purulent process, the temperature rises, the blood test shows leukocytosis, an increase in ESR.

Treatment. In the acute stage of the disease, the patient is prescribed bed rest, antibiotics, vitamins, and an ice pack is placed on the area of ​​the affected gland.

At purulent inflammation hospitalization and surgical treatment are required - opening of a purulent focus with subsequent introduction of turundum into its cavity with hypertonic 10% sodium chloride solution, and then with Cherry ointment. At the stage of resorption of the process, physiotherapeutic treatment sessions (UHF, ultrasound) are indicated.

In the area of ​​the vulva, perineum, as well as the vagina and cervix, they sometimes develop genital warts. The cause of condylomas is considered to be a filterable virus. Secondary addition of pyogenic flora causes inflammation and necrosis of condylomas.

Treatment of condylomas consists of sprinkling them with resorcinol powder with boric acid, and when large quantities- removal by surgery or electrocoagulation.

Colpitis is inflammation of the vagina. Signs of the disease are heavy discharge (leucorrhoea), often pain in the vagina. The walls of the vagina are hyperemic, swollen, and sometimes pinpoint bright red rashes and purulent deposits are visible. With trichomonas colpitis, the discharge is purulent, yellow-green, foamy, and with thrush - in the form of white curdled masses.

Treatment should be comprehensive, taking into account the pathogen, microscopic and microbiological examination data. General anti-inflammatory treatment is carried out in combination with local application disinfectants, antibacterial, anti-inflammatory agents. Treatment of recurrent colpitis is long-term, courses last 2-3 weeks. After use antibacterial drugs it is imperative to prescribe medications to restore normal vaginal microflora - lactobacterin, bifidumbacterin and dialact for local use.

In childhood and old age, simultaneous inflammation of the vagina and external genitalia is more often observed - vulvovaginitis. In girls, vulvovaginitis often develops when pinworms infect the rectum, with urinary tract disease, and also when foreign bodies enter the vagina. In these patients, it is necessary to pay special attention to identifying gonorrhea, which, as a rule, has a domestic route of infection.

The specifics of treatment for vulvovaginitis depend on the etiology of the disease.

Endocervicitis- inflammation of the mucous membrane of the cervical canal. The disease manifests itself as leucorrhoea and sometimes nagging pain in the sacral area. In the acute stage of inflammation, when examining the cervix with the help of mirrors, hyperemia around the external pharynx, mucopurulent or purulent discharge from the cervical canal are noted. In the chronic course of the process, hyperemia is expressed insignificantly, the discharge from the cervical canal is mucous and cloudy. Long-term chronic course of endocervicitis leads to hypertrophy (thickening) of the cervix - cervicitis.

Treatment - comprehensive local and general with the use of antibacterial, anti-inflammatory, vitamin (A And E) and restorative drugs.

Cervical erosion is damage, a defect in the stratified squamous epithelium on the vaginal part of the cervix around the external os. Such erosion is usually called true. It is formed as a result of irritation of the cervix by pathological discharge from the cervical canal during endocervicitis. True erosion is bright red in color, irregular shape, bleeds easily when touched.

The stage of true erosion does not last long (1-2 weeks), its healing soon begins. In the first stage of healing (pseudo-erosion), the defect of the stratified squamous epithelium is replaced by a cylindrical one, spreading from the cervical canal. This epithelium is brighter in color compared to stratified squamous epithelium, so the surface of the erosion remains bright red. Pseudo-erosion can exist for many months and even years if left untreated.

When the inflammatory process subsides spontaneously or under the influence of treatment, stage II of erosion healing occurs, in which the stratified squamous epithelium from the edges begins to displace or cover the columnar epithelium. Often, small (Nabothian) cysts remain at the site of former erosion, which are the result of blockage of the excretory ducts of the erosive glands. Erosions are often formed when the mucous membrane of the cervical canal is everted (ectropion) at the site of former ruptures - eroded ectropion.

It is now known that cervical erosion can be not only a consequence of inflammation, but also the result of congenital and dystrophic changes in its epithelium, as well as hormonal disorders in a woman’s body. If there is erosion, the woman is worried pathological discharge, usually mucopurulent in nature, sometimes contact bloody issues and nagging pain in the sacral area.

Treatment of chronic cervicitis in combination with cervical erosion is long-term. Initially, conservative treatment is carried out (hygienic douching, medicinal baths, tampons or balls with antimicrobial drugs, rosehip oil, sea buckthorn, fish oil). The lack of effect from the therapy is an indication for a biopsy of cervical erosion (after colposcopy), followed by electrocoagulation, cryotherapy, and laser therapy. With eroded ectropion, they often produce plastic surgery on the cervix. Endometritis- inflammation of the uterine mucosa.

Sometimes the inflammatory process also affects the muscular layer of the uterus. Endometritis is manifested by cloudy, sometimes purulent discharge from the genital tract, aching pain in the lower abdomen and in the sacral area. Acute endometritis is characterized by a general reaction of the body to the inflammatory process: increased body temperature, tachycardia, chills. The main clinical sign of chronic endometritis is menstrual dysfunction, mainly in the form of bleeding. In modern conditions, endometritis can occur in an erased form from the very beginning.

Salpingo-oophoritis (adnexitis)- inflammation of the uterine appendages. The disease in the acute stage is characterized by intense pain in the lower abdomen, more pronounced on the affected side. Often salpingoophoritis is bilateral and is combined with inflammation of the uterus. Body temperature is usually elevated, and with purulent inflammation it can be high and accompanied by chills. As the inflammatory process increases, a purulent saccular tumor sometimes develops in the area of ​​the uterine appendages - a tubo-ovarian tumor.

Inflammatory diseases of the uterine appendages cause infertility, ectopic pregnancy, menstrual dysfunction, etc.

Parametritis- inflammation of the periuterine tissue. This disease is characterized by pain in the lower abdomen with irradiation to the legs and sacral area, difficulty urinating and defecating due to severe pain, deterioration of general condition, increase in body temperature. When the parametric infiltrate suppurates, its contents may leak into the bladder or rectum.

Pelvioperitonitis- inflammation of the pelvic peritoneum, most often resulting from the spread of infection into the abdominal cavity from the infected uterus, tubes and ovaries. With this disease, severe pain in the lower abdomen, deterioration of general condition, and high temperature are noted. The disease may be accompanied by vomiting, retention of stool and gas, and intoxication symptoms: rapid pulse, decreased blood pressure, and a feeling of dry mouth. When examining the patient, symptoms of peritoneal irritation are evident in the lower parts of the abdomen.

Peritonitis- diffuse inflammation of the peritoneum, resulting from the progression of purulent pelvioperitonitis or rupture purulent formation uterine appendages. The disease is characterized by an increase in intoxication, an increase in body temperature to high numbers, and signs of irritation of the peritoneum, expressed in all parts of the abdomen. The development of diffuse peritonitis requires emergency surgical intervention.

Treatment of patients suffering from acute, subacute inflammatory process and exacerbation of chronic inflammatory process of the uterus, appendages and surrounding tissues is carried out in a hospital setting. Treatment of these diseases is complex, carried out according to uniform principles, depends on the stage of the process and includes: antibacterial, detoxification, restorative, sedative, desensitizing, symptomatic therapy, physiotherapy, and, if indicated, surgical treatment.

The choice of antibiotics is determined by the microflora that caused the disease and its sensitivity to them. More often, a combination of antibiotics and drugs that act on anaerobic bacteria is prescribed. (metronidazole, clindamycin, etc.), as well as with nitrofurans. In the case of tubo-ovarian formations or the development of peritonitis, surgical treatment is necessary.

In chronic stages of the disease, vitamin therapy with physiotherapy is used, spa treatment(balneo- and mud therapy).

Specific inflammatory diseases female genital organs develop as a result of a specific infection (gonorrhea, tuberculosis, trichomoniasis, chlamydia, AIDS, etc.).

Gonorrhea is a specific infectious disease caused by Neisser gonococcus. Gonorrhea is usually transmitted through sexual contact, and less commonly (in children) through household transmission. The incubation period ranges from 3 to 6 days.

Gonococcus infects mucous membranes covered with cylindrical epithelium, therefore, when infected, the primary foci of the disease are the mucous membranes of the cervical canal, the urethra with paraurethral ducts and the excretory ducts of the large vestibular glands. The pathological process in the area of ​​primary lesions is usually called gonorrhea of ​​the lower female genital organs.

The spread of infection in gonorrhea occurs in an ascending way through the mucous membranes, or intracanalicularly. As a result of the penetration of gonococcus beyond the internal os of the cervix, gonorrhea of ​​the upper genital organs, or ascending gonorrhea, develops. This affects the endometrium, fallopian tubes, ovaries and pelvic peritoneum. Abscesses of the fallopian tubes (pyosalpinxes) and ovaries (pyovariums) often form.

The occurrence of ascending gonorrhea is facilitated by menstruation, abortion, childbirth, diagnostic curettage of the mucous membrane of the uterine body, and poor sexual hygiene.

According to the clinical course, fresh (up to 2 months from the moment of illness) and chronic gonorrhea are distinguished. There are acute, subacute and torpid (erased) forms of fresh gonorrhea. In recent years, cases of torpid diseases have become more frequent. In addition to the listed forms, there is latent gonorrhea. With this form, there are no symptoms of the disease, gonococci are not detected in smears, and patients are an undoubted source of infection. In the torpid form of gonorrhea, in contrast to the latent form, gonococci are found in smears.

The clinical picture of acute gonorrhea of ​​the lower genital organs is manifested by profuse purulent leucorrhoea and frequent painful urination. During a gynecological examination of the patient, hyperemia is noted in the area of ​​the external opening of the urethra and the external os of the cervix, and mucopurulent discharge from the cervical canal.

The torpid form of gonorrhea occurs without pronounced clinical symptoms, so the patient may not see a doctor and be a source of infection for a long time.

Ascending gonorrhea is characterized by an acute onset, severe general intoxication and rapid reversal of the process after administration. antibacterial therapy. In the torpid form of ascending gonorrhea, the disease proceeds sluggishly, accompanied by unexpressed aching pain in the lower abdomen.

Gonorrhea of ​​the upper genital organs involving the uterine appendages is most often bilateral and leads to infertility as a result of obstruction of the fallopian tubes.

Diagnosis of gonorrhea is based on identifying gonococcus in the urethra, cervical canal, and sometimes in discharge from the vestibular glands and rectum (bacterioscopic and bacteriological studies). With torpid and chronic course gonorrhea, to detect the pathogen, provocation methods are used, causing an exacerbation of the process.

Treatment of patients suffering from gonorrhea of ​​the lower genital organs is carried out in regional venereal dispensaries, where a notification is sent and a woman is referred after gonococcus is detected in her smears. Patients suffering from ascending gonorrhea are usually treated in a gynecological hospital. The principles of treatment for patients with gonorrhea do not differ from those for patients with an inflammatory process of septic etiology. General therapy(antibacterial, desensitizing, detoxifying, etc.) in the subacute and chronic stages is combined with local treatment of lesions.

For this purpose it is used 1-3% silver nitrate solution, 1-3% protargol solution, 5% collargol solution. IN venereal dispensary In addition to treatment, the patient is confronted (identifying the source of infection). After treatment is completed, the patient is carefully examined to determine whether she is cured. For this purpose, smears are taken from the patient during three menstrual cycles on the days of menstruation (on the 2-4th day). If during this time no gonococcus is detected in smears, then the patient is considered cured of gonorrhea (cure criterion).

Trichomoniasis- a specific infectious disease caused by Trichomonas vaginalis. Trichomoniasis is usually transmitted through sexual contact. Extrasexual transmission is rare. The incubation period is 5-15 days.

The clinical picture of the disease is characterized by symptoms of colpitis. Sometimes the urethra, bladder and rectum are affected. Patients usually complain of profuse leucorrhoea, itching in the area of ​​the external genitalia and vagina. The walls of the vagina are hyperemic, swollen, and there is abundant yellow-green foamy discharge. When the clinical symptoms of trichomoniasis are mild, patients do not always consult a doctor in a timely manner. In such patients, the disease is characterized by a protracted course and a tendency to relapse.

Recognition of trichomoniasis is carried out by microscopic examination of discharge from the vagina, cervix and urethra.

Treatment of trichomoniasis is carried out on an outpatient basis with special oral bactericidal drugs: trichopolum, flagyl, trichomonacid, fasigin. Local treatment of trichomoniasis consists of daily treatment of the vagina with disinfectant solutions and injection into the vagina metronidazole in the form of candles, Klion-D in the form of vaginal tablets. At the same time as the patient, her partner should be treated with oral medications according to the same regimen.

Cure criteria: during three menstrual cycles, smears are taken on the days of menstruation. If Trichomonas are not detected, then the patient is considered cured of trichomoniasis.

Tuberculosis genitals women, caused by Mycobacterium tuberculosis, is a secondary disease. The history of a patient with genital tuberculosis usually indicates tuberculosis of the lungs or other organs in the past.

The fallopian tubes and uterus are most often affected, less commonly the ovaries and extremely rarely the vagina and external genitalia. Typically, the disease manifests itself during the formation of menstrual function and the beginning of sexual activity. It proceeds sluggishly, without pronounced pain syndrome, with low-grade fever body, which does not decrease as a result of nonspecific anti-inflammatory therapy. Menstrual dysfunction is often observed in the form of bleeding at the onset of the disease and scanty menstruation until its complete cessation during a prolonged process. A characteristic symptom genital tuberculosis is primary infertility.

If genital tuberculosis is suspected, the patient should be referred for consultation to an anti-tuberculosis dispensary, where she undergoes special examination and treatment to confirm the diagnosis.

Treatment, as well as diagnosis, should be carried out in specialized TB institutions.

Candidiasis - an infectious disease of the vagina that spreads to the cervix and often to the vulva. The causative agent is yeast-like fungi, most often of the genus Candida. The occurrence of candidal colpitis is facilitated by diseases that reduce the body’s defenses (diabetes mellitus, tuberculosis, diseases gastrointestinal tract etc.), as well as long-term use of antibiotics and hormonal contraceptives, leading to dysbacteriosis.

Candidiasis is especially often detected in pregnant women, which is due to changes in the endocrine and other body systems that occur during pregnancy. Patients complain of leucorrhoea, itching and burning in the vulva area. Leucorrhoea can be worn different character, often have an admixture of cheesy-crumbly inclusions. Upon examination, grayish-white deposits of a cheesy nature are noted on the affected mucous membranes of the genital organs. After removing the plaque, a brightly hyperemic mucous membrane is revealed.

The course of candidiasis can be long, lasting for years with periodic relapses, despite treatment, which is especially typical in the presence of other foci of candidiasis in the body.

Clarification of the diagnosis is based on the detection of the pathogen in smears taken from the affected areas.

Treatment is complex, directed directly against the pathogen and including treatment of concomitant diseases. A combination of oral antifungal drugs is mandatory ( nystatin, nizoral, diflucan) With local treatment. Used intravaginally ginopevaril, gynotravogen, miconazole, nystatin in candles, cloprimazole, pimafucin in vaginal tablets and cream, tampons soaked 10-20% solution of borax in glycerin, etc. Treatment courses also include vitamins, sedatives, restoratives and desensitizing agents.

Chlamydia caused by chlamydia (an intermediate form between bacteria and viruses), transmitted sexually, characterized by a long course, insufficient severity of clinical signs, and a tendency to relapse.

Chlamydia can coexist with mycoplasmas, gonococci and other bacteria. The incubation period lasts 20-30 days. The primary focus of infection is usually located in the mucous membrane of the cervix, characterized by purulent (seropurulent) discharge from the cervical canal and hyperemia around the external os. It is possible to develop chlamydial urethritis, which is accompanied by dysuric symptoms or occurs against a background of mild symptoms.

Chlamydial infection affects almost all parts of a woman’s genital organs, causing the development of bartholinitis, cervicitis, pseudo-erosion on the cervix, endometritis, salpingitis, and pelvioperitonitis. As a result, violations of the basic functions of the reproductive system occur, often leading to infertility.

Chlamydia in pregnant women deserves special attention, since they have a risk of infection during childbirth (chlamydial conjunctivitis, pneumonia, etc.).

Clinical manifestations of chlamydia are nonspecific and, as a rule, differ little from signs of diseases caused by other microorganisms.

Diagnostic methods can be divided into two groups.

The first group includes the detection of a pathogen (or its antigen) by immunofluorescence and enzyme immunoassay methods in the affected tissue. The most accessible material is smears from the cervical canal, obtained by superficial scraping. The second diagnostic method is based on determining antibodies against chlamydia in the patient’s blood serum.

Currently, the most specific method has been developed - determination of pathogen DNA in pathological material (DNA diagnostics).

The success of treatment depends on early diagnosis and timely treatment, simultaneous examination and treatment of the husband (sexual partner), cessation of sexual activity until complete recovery, prohibition of the use of alcohol and spicy food. The basis of therapy is antibiotics: tetracyclines (mainly doxycycline), macrolides ( erythromycin, sumamed, rulid), fluoroquinolones ( abaktal, tsiprobay, tsifran). It is necessary to simultaneously prevent candidiasis nystatin, nizoral and etc.

Viral diseases are among the common infections of the genital organs and can be caused by various viruses. Some viruses (for example, cytomegalovirus, hepatitis B virus) do not cause noticeable changes in the genitals, but during pregnancy they pose a real threat to the fetus. The most clinically pronounced diseases of the genital organs are caused by the herpes simplex virus and papillomavirus.

Herpes simplex virus is the causative agent of herpetic diseases of the genital organs, is transmitted sexually and persists for life in regional lymph nodes and nerve ganglia, periodically leading to relapses of infection. The main reservoir of the virus in men is the genitourinary tract, in women it is the cervical canal.

Clinical symptoms of genital herpes usually appear after 3-7 days of the incubation period. Local manifestations (erythema, vesicles, ulcers) occur on the mucous membranes of the vulva, vagina, cervix, sometimes in the urethra and perineum. They are accompanied by itching, burning, pain, as well as general malaise, headache, low-grade fever, etc.

Expressiveness clinical picture, the frequency of relapses and the duration of remissions vary individually within wide limits. The occurrence of relapses is facilitated by such factors as stress, overwork, hypothermia, and the addition of other diseases. If the upper parts of the reproductive system are affected, infertility is possible. The disease is sometimes asymptomatic. Genital herpes can be adverse consequences during pregnancy: the fetus may become infected and develop developmental abnormalities.

For diagnosis, various complex methods (electron microscopic, etc.) are used to detect the virus in the discharge from the affected organs or antibodies to it in the patient’s blood serum.

Antiviral drugs are used for treatment - Zovirax (Virolex, Acyclovir), Famvir, Alpizarin, Helepin and others, which temporarily stop the spread of the virus, reduce the frequency of relapses, but do not cure the disease. Antiviral drugs in the form of an ointment ( Zovirax, Bonafton, Gossypol, Triapten, etc.) is used topically when the first symptoms of a herpes infection appear. To prevent and treat relapses of the disease, immunocorrective therapy is prescribed.

Broadcast human papillomavirus infection occurs only sexually. This disease is also known as condylomas. The most common are pointed condylomas, located mainly in the area of ​​the labia majora and minora, less often in the vagina, on the cervix and in the perineum. Possible proliferation of condylomas, especially during pregnancy.

Treatment consists of treating condylomas feresol, coidilin (0.5% podophyllotoxin solution), and if there is no effect - removal using cryodestruction, carbon dioxide laser, electrocoagulation. Bacterial vaginosis- a disease (previously called gardnerellosis), in which there is a disruption of the normal microflora of the vagina (vaginal dysbiosis) with a predominance of opportunistic pathogens: gardnerella, bacteroides, mycoplasmas and other microorganisms. The disease is asymptomatic; leukocytes and pathogenic pathogens are not detected in the vaginal secretion. Patients complain of profuse leucorrhoea with an unpleasant smell of rotten fish.

Diagnostic signs are an increase in the pH of the vaginal environment more than 4.5 (normally 3.8-4.2); presence of key cells on vaginal smear microscopy, positive amine test (when added to the vaginal contents 10% potassium hydroxide solution a sharp, specific smell of fish is detected).

Treatment is aimed at restoring normal vaginal microflora. Desensitizing and immunocorrective therapy is carried out. At the first stage of treatment, drugs are applied topically metronidazole(in gel, suppositories, tablets) or vaginal form clindamycin(dalacina-C). Oral metronidazole or clindamycin can be used at this stage. At the second stage, biological products (eubiotics) are prescribed intravaginally: lactobacterin, bifidumbacterin, acylact.

Infectious diseases of the female genital organs that are sexually transmitted (such as syphilis, gonorrhea, trichomoniasis, chlamydia, ureaplasmosis, candidiasis, genital herpes, etc.) are combined into a general group under a single name: sexually transmitted diseases (STDs) .

HIV infection is a disease caused by the human immunodeficiency virus (HIV), which persists for a long time in lymphocytes, macrophages, and nerve tissue cells. As a result of exposure to the virus, slowly progressive damage to the immune and nervous systems of the body develops, manifested by secondary infections, tumors, subacute encephalitis and other pathological processes leading to the death of the patient. HIV infection occurs through several stages, the last of which is referred to as “HIV syndrome.”

Gynecology- teaching, science about women (from the Greek gyne - woman, logos - teaching), which studies the anatomical and physiological characteristics of the female reproductive system and its diseases, diagnostic methods, treatment and prevention.

Examination of gynecological patients consists of a survey and an objective examination. Diagnosis and treatment of gynecological diseases is impossible without a thorough collection and assessment of anamnesis data, which is divided into general and special gynecological. An objective examination also includes general and special gynecological examination methods.

The collection of anamnesis begins with clarifying passport data (particular attention is paid to the patient’s age), the patient’s complaints, and identifying the possibility of hereditary diseases in close relatives. The age of the patient is important due to the fact that various gynecological diseases are characteristic of a certain age.

The following age periodization is currently accepted:

• 1. Newborn period (1-10 days).
• 2. Childhood period (up to 8 years)
• 3. Puberty (8-18 years), which is divided into stages:
  • · prepubertal (7-9 years)
  • Puberty (10-18 years)
• 4. Reproductive period(18-45 years old)
• 5. Perimenopausal (menopausal) period (45-55 years)
• Premenopause (from 45 years to the last menstruation)
• Menopause (1 year after last menstruation)
• 6. Postmenopause (after menopause until the end of life)

Rational anamnesis chart presented like this:

• 1. Passport data (full name, gender, age, place of residence, place of work, position).
• 2. Living conditions.
• 3. Related complaints.
• 4. Previous illnesses: diseases childhood, somatic, infectious (including Botkin's disease) operations, injuries, heredity, allergic history, blood transfusions, husband's diseases.
• 5. Lifestyle, nutrition, bad habits, working and living conditions.
• 6. Special obstetric and gynecological history:
• 1) the nature of menstrual, sexual, reproductive, secretory functions;
• 2) previous gynecological diseases and genital surgeries;
• 3) previous urogenital and venereal diseases,
• 7. History of the present illness.

Gynecological examination- a set of methods for studying the female reproductive system, which is divided into basic ones, which are mandatory for examining all patients, and additional ones, i.e. according to indications and depending on the presumptive diagnosis.

Basic methods

• 1. Examination of the external genitalia It is performed after emptying the bladder and, preferably, the intestines, with the patient lying on the gynecological chair on her back with her legs bent at the knees and hip joints. The study is carried out using disposable rubber gloves. Attention is drawn to the nature and degree of hair growth, the size of the labia minora and majora, the presence of pathological processes - ulcers, swelling, hypertrophies, fistulas, scars, varicose veins etc. By spreading the labia with the thumb and index finger of the left hand, the vestibule of the vagina, the external opening of the urethra, the paraurethral passages, the hymen and the excretory ducts of the large vestibular glands, and discharge are examined. The clitoris is examined, its shape and size are determined.
• 2. Inspection using mirrors precedes a vaginal examination and is accompanied by taking smears for bacterioscopic and cytological examination. Vaginal specula can be cylindrical, folded or spoon-shaped. Having exposed the cervix, they examine its shape, the presence of scars, ulcers, polyps, fistulas, the condition of the vaginal walls, etc.
• 3. Internal study- divided into vaginal (one-handed), bimanual (vaginal-abdominal or two-handed), rectal and rectovaginal. Vaginal examination is performed with the second and third fingers of the right hand. First you need to spread the labia majora and minora with your left hand, then pull the posterior commissure of the vagina downwards with the third finger of your right hand and then carefully insert the second finger. In this case, the thumb is directed to the symphysis (without touching the clitoris), ring finger and the little finger are pressed against the palm, and the back of their main phalanges rests against the perineum. The condition of the vagina, volume, folding, distensibility, the presence of pathological processes, vaginal vaults, the area of ​​the large vestibular glands, the urethra, and part of the cervix are assessed.

During a vaginal-abdominal or bimanual (two-handed) examination, the condition of the uterus, appendages, ligaments, pelvic peritoneum and tissue, as well as neighboring organs, is determined. When palpating the uterus, its position, size, shape, consistency, and mobility are determined. To inspect the appendages, move the fingers of the inner hand to the left lateral fornix, while simultaneously moving the outer hand to the left inguinal-aerial region, and the right appendages are examined in the same way. Normally, the tubes and ovaries are usually not palpable.

Rectal and rectovaginal examination is used in girls, women with vaginal stenosis or atresia, or to obtain additional information. This study helps to palpate back surface uterus, tumors and infiltrates in the retrouterine space.

TO additional research methods relate:

Bacterioscopic examination allows you to establish a type of microbial factor in the vagina, cervical canal and urethra. Pathological secretion - leucorrhoea can be a manifestation of disease in different parts of the genital organs. There are tubal leucorrhoea, uterine or corporal (endometritis, initial stage endometrial cancer), cervical (endocervicitis, erosion, polyps, etc.).

Cytological examination is one of the most important diagnostic methods (oncocytology), allowing to identify pathological changes in cells. The material is obtained from the surface of the cervix, cervical canal, from the uterine cavity, pleural and abdominal cavities using a spatula, cervical cytobrush, by aspiration of the contents of the uterine cavity or tumor, abdominal cavity, and also by the method of fingerprint smears.

Instrumental research methods

Probing of the uterus carried out to determine the patency of the cervical canal, the length of the uterus, deformation of the uterine cavity and developmental anomalies, the presence of a tumor. It is used before curettage of the uterine cavity or amputation of the cervix.

Separate diagnostic curettage mucous membrane of the uterine body and cervical canal is widely used in cases of suspected malignant tumor, endometrial polyposis, uterine bleeding of unknown etiology.

Methodology: under aseptic conditions, a spoon-shaped speculum is inserted into the vagina and bullet forceps are applied to the anterior lip of the cervix. First, the mucous membrane of the cervical canal is scraped out with a small curette without expansion and the scraping is placed in a 10% formaldehyde solution. Then the uterine cavity is probed, the length of the uterus and its position are determined. Using Hegar dilators, the cervical canal is widened and the uterine mucosa is scraped out with a curette from the fundus to the cervical canal, the uterine angles are carefully scraped out. The scraping is also placed in a 10% formaldehyde solution, and both scrapings are sent to the laboratory for histological examination.

Biopsy used when pathological processes cervix, vagina or external genitalia. It is performed after a colposcopic examination of the cervix.

Methodology: under aseptic conditions, the cervix is ​​exposed, bullet forceps are applied to both sides of the area to be removed, and the pathological area is excised between them with a scalpel. The biopsy can be taken with a conchotome, or with diathermoexcision, or with the help of a CO 2 laser, or a radioknife. The resulting material in a 10% formaldehyde solution is sent for histological examination.

Endoscopic methods

Colposcopy- examination of the cervix and vaginal walls with a magnification of 10-30 times or more. This makes it possible to identify early forms of precancerous conditions and select the area most suitable for biopsy. If you have a photo attachment, it is possible to document detected changes. Stands out simple colposcopy, those. examination of the cervix with determination of the relief of the mucous membrane, the border of the squamous epithelium covering the cervix, and the columnar epithelium of the cervical canal.

Extended colposcopy, when the examination is carried out after treating the cervix with a 3% solution of acetic acid, which causes short-term swelling of the epithelium, swelling of the cells of the spinous layer and a decrease in blood supply. The action of acetic acid lasts 4 minutes. After examining the cervix with a colposcope, a Schiller test is performed - the cervix is ​​lubricated with 3% Lugol's solution. The iodine contained in the solution stains glycogen in the cells of healthy, unchanged squamous epithelium of the cervix in a dark brown color, while pathologically altered cells are poor in glycogen and do not stain.

Colpomicroscopy- intravital histological examination of the vaginal part of the cervix. Before examination, the cervix is ​​stained with a 0.1% hematoxylin solution, and the tube of a contrast fluorescent colposcope is brought directly to the cervix. In the unchanged neck, squamous epithelial cells have a polygonal shape, clear boundaries, the cell nuclei are colored purple, the cytoplasm is blue, the subepithelial vessels are uniform, straight, their bed is not widened.

Hysteroscopy- examination of the walls of the uterine cavity using optical systems. Currently, hysteroscopy in combination with histological examination is the gold standard in diagnosing endometrial conditions.

Types of provocations

• 1. Chemical provocation - lubricating the urethra to a depth of 1-2 cm with a 1-2% solution of silver nitrate, the lower rectum to a depth of 4 cm with a 1% Lugol's solution in glycerin.
• 2. Drug provocation - intramuscular administration of gonovaccine containing 500 million microbial bodies (mt), or gonovaccine simultaneously with pyrogenal (200 µg).
• 3. Thermal provocation - diathermy is carried out daily for 3 days consecutively for 30,40,50 minutes. Or iductothermy for 3 days for 15-20 minutes.
• 4. Biological methods of provocation - these include the physiological menstrual cycle in women. The analysis is scheduled for 4-5 days of the cycle.

Method of taking a smear

gynecological biopsy colposcopy uterus

When taking material, the nurse should remember the need to follow the rules of asepsis and antisepsis. To take smears, only sterile instruments are used (the same instrument cannot be used to take smears from different places). Smears are taken before a gynecological examination of the patient, as well as before vaginal medical procedures.

A smear is taken from a woman in a lying position on a gynecological chair. First of all, swabs are taken from the urethra; for this, a finger inserted into the vagina is gently massaged. The first portion of discharge from the urethra should be removed with a cotton ball, and then inserted into the urethra (to a depth of no more than 1.5-2 cm) the tip of the tweezers or a special spoon (Volkmann). The material from the urethra is obtained by lightly scraping and applied in the form of a circle on two glass slides with a U mark.