What is more unpleasant, palpation of the uterus or ovaries? Examination of the internal genital organs. Diagnostic methods and symptoms of ovarian apoplexy

Inflammation of the ovaries ( oophoritis) is an acute or chronic pathological process that affects the tissue of the female reproductive glands, causing a disorder in their function. In the vast majority of cases, this disease does not develop independently, but in combination with the inflammatory process within the fallopian tubes ( so-called adnexitis). In foreign literature, acute inflammation of the ovaries is usually combined with inflammation of the fallopian tubes ( salpingitis) into one common clinical syndrome – inflammation in the pelvis.

In most cases, inflammation of the ovaries and uterine appendages occurs due to the penetration of various infectious agents, more often pathogens of sexually transmitted diseases. For this reason, oophoritis and salpingitis usually develop in young women under the age of 25 who are sexually active and do not use barrier methods of contraception ( condoms).


Inflammation of the ovaries, provoked by pathogenic bacteria or viruses, is a dangerous and serious illness that causes reproductive disorders ( infertility), as well as hormonal imbalances due to changes in endocrine activity ovaries. With an aggressive course of the disease, local or widespread purulent complications may occur, posing an immediate threat to the woman’s life.

Interesting Facts

• the inflammatory process in the area of ​​the ovaries and fallopian tubes is one of the most common causes of female infertility;
• inflammation of the ovaries quite often occurs against the background of the asymptomatic course of some sexually transmitted diseases ( chlamydia);
• inflammatory process in the pelvic area is more common among young women;
• isolated damage to the ovaries by an infectious or inflammatory process practically does not occur;
• inflammation of the ovaries can occur in response to an inflammatory process in other organs;
• hormonal disruptions increase the likelihood of infectious agents entering the upper parts of the female reproductive system;
• stress is a factor that significantly weakens the protective potential of the female body and increases the risk of damage to the fallopian tubes and ovaries.

Anatomy of the uterine appendages

The lower parts of the female genital organs are represented by:

• Vulva. The vulva is the labia minora and majora, which serve as the entrance to the vagina, clitoris, and urethral opening.
• Vagina. The vagina is a tubular, muscular-elastic organ that performs sexual, reproductive, protective and excretory functions. Normally, the vaginal environment is not sterile and is formed by Doderlein's bacilli and a number of other saprophytic ( non-pathogenic) microorganisms. Thanks to this, the vagina has its own microflora, which helps protect it from the entry and development of any infections.
• Cervix. The cervix is ​​the part of the uterus located between the vagina and the uterine cavity. A canal passes through the cervix, which is normally closed and contains cervical mucus, which protects the overlying structures from infection.

• Ovaries. The ovaries are paired female sex glands, which are located in the pelvic cavity and perform reproductive and hormonal functions. Produce steroid sex hormones ( estrogen and progesterone). The process of egg maturation occurs in the ovaries.
• Uterus. The uterus is a muscular organ located in the pelvic cavity. Performs reproductive function ( carrying a pregnancy) and menstrual ( detachment of the inner mucosa). Through the fallopian tubes, the uterus connects to the abdominal cavity, and through the cervical canal to the vagina and the external environment.
• Uterine ( fallopian) pipes. The fallopian tubes are a paired organ that is located in the pelvic cavity and connects the uterus to the abdominal cavity. Fertilization of the egg occurs in the lumen of the fallopian tubes, and their main function is the transport of the embryo or egg into the uterine cavity.

The ovaries are supplied with blood by the ovarian artery, which originates from the abdominal aorta, as well as by branches of the uterine artery. Venous blood flows through the ovarian vein, which forms the ovarian plexus, into which blood from the fallopian tubes also flows. Knowledge of the characteristics of the blood supply allows us to better understand the possible mechanisms of penetration of infectious agents to the ovaries.

The ovaries are innervated by branches of nerves from the lower hypogastric plexus. The ovaries are not covered by the peritoneum, but are in fairly close contact with it. These facts are of great importance for understanding the mechanisms of pain during the development of the inflammatory process.

Next to the ovaries is the bladder, intestinal loops, appendix, and rectum. These formations may not be directly adjacent to the ovaries, but in some conditions they can serve as the initial source of infection or inflammation.

Causes of ovarian inflammation

• Infections. In the vast majority of cases, the inflammatory process in the ovaries occurs due to infection, which can be bacterial, viral or fungal in nature. Most often, oophoritis is associated with sexually transmitted diseases, but it can also occur with tuberculosis and with some nonspecific infectious processes. It should be understood that the infection rarely affects only the ovaries and usually affects either the uterus, or the fallopian tubes, or both organs at the same time and only after that it affects the ovaries. However, in some cases, the infection can penetrate into the ovaries and from other organs through direct contact with the infectious-inflammatory focus or through the introduction of pathogenic agents along with the bloodstream.
• Mechanical damage. Trauma to the ovaries, fallopian tubes or uterus can cause an inflammatory process that can engulf the ovaries, as well as significantly weaken local immunity and become a factor predisposing to infection.
• Inflammation of neighboring organs. The entry of biologically active pro-inflammatory substances into the ovaries can trigger some inflammatory reaction.
• Necrosis and inflammation of neoplasms ( tumors). With the development of some tumors, a necrotic process may occur, which can trigger an inflammatory reaction.

Sexually transmitted infections

Oophoritis can be caused by the following pathogens:

• Gonococci. Gonococci are the causative agents of gonorrhea, one of the most common sexually transmitted diseases. These microorganisms penetrate the reproductive system during unprotected sexual contact with an infected partner. Initially they affect the lower parts of the reproductive tract, but when local or general immunity is weakened, as well as when a number of predisposing factors develop, they can penetrate the uterine cavity, move to the fallopian tubes and cause infection of the ovaries.
• Chlamydia. Chlamydia is the causative agent of chlamydia, a common sexually transmitted disease characterized by a latent course. Like gonorrhea, this disease is transmitted during unprotected sex, but unlike gonorrhea, chlamydia rarely causes any very bothersome symptoms. For this reason, this infection is often diagnosed already at the stage of development of various complications, including oophoritis.
• Trichomonas. Trichomonas vaginalis are the causative agents of trichomoniasis, a sexually transmitted infection, which, according to the World Health Organization, is the most common among people. Just like chlamydia, trichomoniasis of the lower genital tract quite often occurs asymptomatically or with minor clinical manifestations. This creates the preconditions for the spread of the infectious process into the uterine cavity and its appendages. Trichomoniasis extremely rarely affects the ovaries, however, the damage to the fallopian tubes it causes can, one way or another, cause an inflammatory reaction in the female reproductive glands with disruption of their function.
• Mycoplasmas. Mycoplasmas are small bacteria that can cause mycoplasmosis. These microorganisms are opportunistic, in other words, they are capable of causing disease only if there is a significant disturbance in the general condition of the woman and if her local or general immunity is reduced. They are transmitted during sexual contact, as well as through some types of household contact. Mycoplasmosis is characterized by a chronic, asymptomatic course. Penetration into the upper parts of the reproductive system is accompanied by the appearance of signs of severe damage to the genital organs.

Initially, the infectious process affects the external genitalia ( labia minora and majora and adjacent glands), as well as the urethra and vagina. It should be noted that normally the vagina is populated by Doderlein's bacilli, which form its normal environment and perform a protective function, as they do not allow pathogenic microorganisms to colonize this organ. However, in some situations, the vaginal microflora and its protective potential may be disrupted, which creates the preconditions for the development of infection.

Risk factors for infection of the lower genital organs are:

• incorrect use of antibiotics;
• vaginal douching;
• lack of personal hygiene;
• stress;
• diseases of the immune system;
• frequent change of sexual partners;
• unprotected sex.

Risk factors for the spread of infection to the upper parts of the female reproductive system are:

• abortion;
• therapeutic or diagnostic curettage of the uterus;
• installation of intrauterine contraceptives ( spirals);
• spontaneous abortion;

All these factors are due to the fact that the expansion of the cervical canal and the removal of the mucous plug opens the way for infectious agents located in the vaginal cavity.

Subsequently, the infectious process covers the mucous membrane of the uterus, and then the fallopian tubes and ovaries. In some conditions, pathogenic agents can cause the formation of purulent infectious and inflammatory foci in the uterine appendages, which is fraught with serious disruption of the general condition and is associated with a high risk of developing systemic complications.

Additionally, the hematogenous route of penetration of infectious agents into the ovaries is considered. This is due to the peculiarities of the blood supply to the ovaries, which receive part of the arterial blood from the branches of the uterine artery. Thanks to this, pathogens that can remain in the human blood for a short or long time can be introduced into the ovaries along with the bloodstream from the lower parts of the reproductive system.

Viral lesion

Inflammation of the ovaries can be caused by the following pathogens:

• Herpes simplex virus type 2. Herpes simplex virus type 2, also known as genital herpes, can enter the body through defects in the skin, as well as through the mucous membranes of the genitals during unprotected sexual contact with an infected person. It has the ability to integrate into human cells, making a complete cure impossible. Due to its scanty symptoms, genital herpes is a fairly common infection. During the activation period, the virus causes local foci of necrosis of the mucous membrane, which provokes an acute inflammatory reaction.
• Cytomegalovirus. Cytomegalovirus comes from the same family as the herpes simplex virus. It can affect many organs, including the genitourinary system. In most cases it is not particularly dangerous, but against the background of reduced immunity it can cause serious complications. It can cause inflammation of the pelvic organs, either alone or in combination with a number of other pathogens ( usually bacterial in nature).

Separately, it is necessary to mention the human immunodeficiency virus ( HIV), which does not independently affect the upper parts of the female reproductive system, but due to its ability to weaken the immune system, creates the preconditions for infection by other pathogens. In addition, against the background of HIV infection, especially at the stage of acquired immunodeficiency syndrome ( AIDS), optimal conditions are created for infection of the genital organs, including the ovaries, not only by aggressive pathogenic microorganisms, but also by opportunistic pathogens, which are normally harmless to humans.

Tuberculous lesion

Typically, tuberculosis infection occurs by inhaling sputum particles containing the tuberculosis bacillus ( airborne transmission), however, penetration of the pathogen is possible through consumption of contaminated food ( milk and dairy products), as well as through the skin ( rarely). In conditions of reduced immunity or impaired body resistance, the tuberculosis bacillus begins to multiply and develop in the tissues of the lungs, provoking a specific inflammatory reaction. As a result, a primary complex is formed, from which pathogens, along with the bloodstream, can enter the bones, kidneys, eyes, skin and genitals.

The penetration of Mycobacterium tuberculosis into the genital organs is due to the peculiarities of their blood supply. Since the fallopian tubes and ovaries receive blood from the branches of the uterine and ovarian arteries, at the places of their intersection ( so-called anastomoses) the speed of blood flow slows down, and this creates ideal conditions for bacteria to penetrate these organs. The hematogenous route of spread is associated with predominantly bilateral damage to the uterine appendages.

Infection with tuberculosis through sexual contact is considered impossible, since the vaginal environment is extremely unfavorable for Mycobacterium tuberculosis. However, if the pathogen comes into contact with injured or inflamed mucous membranes of the lower parts of the reproductive system, primary infection of the genital organs may occur.

The main problem of tuberculous lesions of the fallopian tubes and ovaries is that this disease in the vast majority of cases is asymptomatic. Women rarely seek medical help due to this infection. This leads to the development of various complications and irreparable structural and functional damage against the background of a long course of the disease.

Mechanical damage to the uterine mucosa and fallopian tubes

Mechanical damage to the ovaries and fallopian tubes is possible in the following situations:

• Blows to the abdominal area. Exposure to a short but strong impulse can cause contusion of many internal organs, including the uterus, fallopian tubes and ovaries. Under the influence of a damaging factor, local structural damage may occur, and partial or complete destruction of blood vessels may occur with impaired local circulation. To minimize the consequences, the body triggers an inflammatory response, which in some cases can cause even more severe damage.
• Penetrating wounds in the abdominal area. Penetrating wounds to the abdominal area can cause damage to the upper parts of the female genital organs, which can cause an inflammatory process. In addition, most penetrating wounds are potentially infected.
• Surgical interventions on the abdominal and pelvic organs. Any surgical intervention, no matter how minimally invasive it may be, injures internal organs to one degree or another. Strong pressure on the genitals through surgical instruments, cutting or cauterization can provoke an inflammatory reaction. In addition, do not forget about foreign materials that may end up in the surgical area ( suture material, various prostheses, stents, gases and solutions) and also cause inflammation.
• Invasive gynecological procedures. Gynecological procedures that involve instrumental effects on the internal genital organs ( abortions, curettage) are associated with some trauma, which directly provokes an inflammatory response. In addition, they reduce local immunity and create preconditions for the penetration of infectious agents.

Inflammation of neighboring organs

The ovaries can be involved in the inflammatory process when the following organs are affected:

• Colon. Inflammation of the large intestine, known as colitis, usually occurs due to an imbalance between normal and pathogenic intestinal microflora ( pathogenic bacteria begin to predominate). In some cases, the intestinal wall may become depleted, and ulcers and even through holes may form in it ( which leads to the development of peritonitis and is extremely dangerous). In addition, the inflammatory process in the intestines is accompanied by swelling, slowing of blood flow and dysfunction. Under the influence of these factors, there is a risk of pathogens passing through the intestinal wall to neighboring organs - the peritoneum, ovaries and fallopian tubes, and other parts of the intestine.
• Appendix. Inflammation of the appendix ( appendicitis) is one of the most common surgical pathologies. There are several theories explaining the mechanism of development of this disease, but regardless of the initial cause, the developing inflammatory reaction affects the entire thickness of the muscular wall of the organ and covers part of the serous membrane covering it. The resulting pathological reaction is quite massive, and upon contact with other organs it can also affect them.
• Bladder. Bladder infection ( cystitis) in some cases can cause an inflammatory process in the ovaries. However, in the vast majority of cases, the ovaries are involved in the inflammatory process not due to contact with the bladder, but due to parallel damage to the internal genital organs and bladder by sexually transmitted infections.
• Peritoneum. The peritoneum is the serous membrane that covers most of the abdominal organs and lines the walls of the abdominal cavity itself. Despite the fact that the ovaries are not covered by the peritoneum, an infectious-inflammatory process on the surface of the peritoneum can cause damage to the ovaries. However, much more often the opposite happens, and inflammation of the ovaries causes local inflammation of the peritoneum - pelvioperitonitis. It should be understood that peritonitis ( inflammation of the peritoneum) is an extremely serious condition that requires immediate medical treatment.

Symptoms of ovarian inflammation

Symptoms of ovarian inflammation are formed by the inflammatory reaction itself, which, one way or another, changes the function and structure of the organ, as well as by infectious agents, which in most cases are the cause of oophoritis.


Inflammation of the ovaries is accompanied by the following symptoms:

• pain in the lower abdomen;
• increased body temperature;
• disruption of the gastrointestinal tract;
• menstrual irregularities;
• painful sexual intercourse;
• hormonal disorders;
• infertility;
• pain in the upper abdomen;
• muscle tension in the anterior abdominal wall.

Pain in the lower abdomen

The duration of pain varies depending on the activity of inflammation and the treatment received. Usually the pain is present for at least 2 - 3 days, but no more than 3 - 4 weeks.

Increased body temperature

There are three stages of fever development:

• Temperature rise. The rate of temperature rise depends on the nature and properties of the pathogen. With a sharp rise, a feeling of chills occurs, which indicates the activation of heat-saving mechanisms ( decreased sweating, goose bumps, contraction of peripheral blood vessels). Body temperature increases due to increased thermogenesis ( muscle tremors, accelerated nutrient metabolism).
• Plateau stage. At the plateau stage ( maintaining body temperature) the feeling of chills disappears and body temperature stabilizes. Depending on the pathogen, body temperature during inflammation of the ovaries can rise to 37.5 - 38 or even 39 degrees. If complications develop, body temperature may exceed 39 degrees.
• Decrease in temperature. The decrease in body temperature can occur either gradually or abruptly. Body temperature decreases after eliminating the effect of pyrogenic substances, when taking certain medications, as well as when the body is severely depleted.

Disorders of the gastrointestinal tract

The following disorders of the gastrointestinal tract may occur:

• Nausea and vomiting. Nausea and vomiting occur reflexively, in response to intense painful stimulation of the hypogastric nerve plexus. In addition, nausea is one of the possible consequences of increased temperature and general intoxication of the body. Vomiting is usually mild and not associated with food intake. Profuse vomiting that does not bring relief indicates the possible development of complications ( peritonitis).
• Diarrhea. Diarrhea occurs due to intoxication of the body, as well as due to irritation of the intestines by an inflammatory focus.
• Urge to defecate. Frequent urge to defecate occurs due to irritation of the ampullary part of the rectum by an inflammatory focus in the genitals and in the area of ​​the peritoneum located in the pelvis.

Pathological discharge from the genital tract

In the presence of infectious and inflammatory foci within the upper or lower genital organs, various pathological vaginal discharges often occur, indicating an illness. The nature of the discharge depends on the nature and properties of the pathogen, as well as on the location of the lesion and the body’s resistance.

It should be understood that discharge can form in the vagina, cervix and uterine cavity. An infectious-inflammatory process limited to the fallopian tubes or ovaries is extremely rarely accompanied by discharge from the genital tract, since much more often in this case pathological fluids drain into the pelvic cavity.

The following options for pathological discharge from the genital tract are possible:

• Purulent discharge. Purulent discharge is a specific sign indicating the bacterial nature of the pathogens. They are a yellowish-green viscous liquid, the amount of which can vary depending on the severity of the process and the aggressiveness of the pathogen. Purulent discharge is characterized by an unpleasant smell of rotten fish. When anaerobic microflora joins, purulent discharge becomes foamy, since these microorganisms produce gas, which foams the pus.
• Serous discharge. Serous discharge is characteristic of viral infection of the cervix and uterus. They arise due to vasodilation and the release of part of the plasma from the bloodstream during an inflammatory reaction. Typically, such discharge is transparent or slightly yellowish, odorless.
• Bloody issues. Bloody discharge occurs when blood vessels melt by pathogenic agents or when their integrity is destroyed during an inflammatory reaction. Bloody discharge is usually scanty, not abundant, represented by dark blood, and occurs regardless of the menstrual period. The discharge may be accompanied by pain in the lower abdomen.

Menstrual irregularities

The menstrual cycle is based on the periodic renewal of the uterine mucosa and the maturation of the egg. This happens in several phases, each of which is regulated by certain hormones. First, detachment of the uterine mucosa occurs ( endometrium), which is accompanied by bleeding. Subsequently, under the influence of sex hormones, regeneration of the mucous layer begins in the uterine cavity, and a dominant follicle is formed in the ovaries. Subsequently, by the time of ovulation, when the follicle ruptures and the level of estrogen and progesterone increases, the uterine mucosa thickens significantly, and the egg released from the follicle ( which at this stage is more correctly called a first-order oocyte) migrates through the fallopian tubes into the uterine cavity. If fertilization does not occur during this period, then this cycle is repeated again.

With inflammation of the ovaries, the menstrual cycle may be disrupted for the following reasons:

• damage to the uterine mucosa;
• decreased levels of sex hormones due to ovarian dysfunction;
• ovulation disorders;
• disruption of endometrial regeneration.

• lack of discharge during menstruation;
• scanty discharge during menstruation;
• heavy discharge during menstruation;
• long menstrual cycle;
• pain during menstruation.

Painful sexual intercourse

Pain during sexual intercourse is associated with excessive vaginal dryness, which occurs either due to inflammatory damage to the vagina itself, or due to a decrease in the level of the sex hormone estrogen. As a result, due to insufficient hydration, friction increases and pain occurs during sex. This leads to a woman's decreased sexual desire ( libido decreases), mood is disturbed, and depression may develop.

Hormonal disorders

Since one normally functioning ovary is capable of maintaining the level of sex hormones within the physiological norm, hormonal disorders occur only when the organ is damaged bilaterally or when the only functioning ovary is affected.

Hormones are known to regulate many physiological processes in the human body. When the level of sex hormones decreases, sexual and reproductive function disorders occur, as well as disorders of the central nervous system ( mood changes, depression, manic-depressive states), of cardio-vascular system ( heart rhythm disturbances, high blood pressure) and from the side of metabolism ( obesity occurs, cholesterol levels increase). Of course, some of these manifestations can develop only in the case of a protracted inflammatory process accompanied by hormonal imbalance.

Infertility

Infertility with ovarian damage is associated with impaired egg production, as well as developing hormonal disorders. However, much more often, infertility occurs due to damage to the fallopian tubes, which in the vast majority of cases accompanies oophoritis. Due to the inflammatory reaction, the fallopian tubes narrow, functional and structural changes occur in them, which lead to partial or complete obstruction of the egg and sperm.

Muscle tension in the anterior abdominal wall

In addition to the symptoms listed above, the inflammatory process localized in the ovaries and fallopian tubes may be accompanied by a number of other signs, which in most cases arise already at the stage of development of complications.

Inflammation of the uterine appendages may be accompanied by the following signs of a complicated course:

• Pain in the upper abdomen and right hypochondrium. A painful sensation in the right hypochondrium, which arose against the background of pain in the lower abdomen, temperature and other signs of damage to the woman’s reproductive system, indicates the occurrence of perihepatitis - inflammation of the liver capsule ( Fitz-Hugh-Curtis syndrome). It is characterized by some dysfunction of the liver, increased levels of liver enzymes, and sometimes yellowness of the skin and mucous membranes.
• Swelling of the abdomen on the affected side. The occurrence of abdominal swelling on the side of the affected ovary, which can be determined visually or during palpation, indicates the development of a tubo-ovarian abscess - a cavity filled with purulent contents. It is a potentially dangerous condition that requires surgical treatment.

Diagnosis of ovarian inflammation

Before starting any diagnostic procedures, a conversation is held with the doctor, during which the main symptoms, the time of their onset, intensity, and main characteristics are clarified. Data are collected on previous surgical operations and on known acute and chronic diseases. The doctor finds out whether the menstrual cycle is regular, when the last menstruation was, what is the amount of discharge during menstruation, whether menstruation is accompanied by pain or discomfort.

An inflammatory process in the area of ​​the uterine appendages is suspected if the following signs are present:

• pain in the lower abdomen;
• pathological discharge from the genital tract;
• increased body temperature;
• hormonal disorders;
• menstrual irregularities;
• recent sexually transmitted diseases;
• frequent change of sexual partners;
• age up to 25 years;
• non-use of barrier contraception methods ( condoms);
• the presence of an intrauterine device;
• recent intrauterine procedures ( abortion, curettage, installation of a spiral).

Diagnosis of oophoritis is based on the following procedures:

• gynecological examination;
• Ultrasound of the pelvic organs;
• microbiological research.

Gynecological examination

With isolated inflammation of the ovaries, a gynecological examination does not reveal any abnormalities. However, since in the vast majority of cases with this disease, other parts of the reproductive system are involved in the infectious-inflammatory process, upon examination a number of nonspecific signs are determined.

During a gynecological examination, the following signs are revealed:

• redness of the vaginal mucosa;
• swelling of the vaginal mucosa and vaginal part of the cervix;
• the presence of ulcers on the surface of the vaginal mucosa;
• the presence of purulent or foamy discharge in the vaginal cavity or in the posterior vaginal fornix;
• traces of pathological discharge at the mouth of the cervical canal.

By bimanual palpation in women with a fairly thin anterior abdominal wall, the ovaries can be palpated, which in case of inflammation are enlarged and painful.

Ultrasound of the pelvic organs

An ultrasound examination of the pelvic organs reveals the following changes:

• Increase in size of the ovaries. During the inflammatory reaction, swelling occurs, which leads to an increase in the size of the organ. The normal dimensions of the ovaries are on average 25 mm wide, 30 mm long, and 15 mm thick.
• Thickening of the fallopian tubes. Since the inflammatory process that engulfs the ovaries, in most cases also involves the fallopian tubes, ultrasound reveals signs of salpingitis ( inflammation of the fallopian tubes). Normally, the fallopian tubes are almost invisible during ultrasound examination, but due to the thickening of the wall during inflammation, they become noticeable.
• Smoothness of the surface of the ovaries. Normally, the surface of the ovaries is slightly bumpy due to the developing follicles. When ovarian function is impaired, as well as due to edema, the surface of the organ is smoothed.
• Strengthening the echo structure. Strengthening the echostructure of the ovaries occurs due to the formation of areas of fibrosis in the thickness of the ovaries.
• Signs of inflammation in the uterine cavity. The inflammatory process in the uterine cavity is a common symptom that accompanies oophoritis. This is revealed by ultrasound by thickening of the endometrium, areas of fibrosis in the uterine cavity, as well as hypoechoic formations in the wall of the organ.

It should be noted that ultrasound examination can be performed using two methods – through the anterior abdominal wall and through the vagina. The latter method is more sensitive and informative.

Laparoscopy

Laparoscopy is carried out by introducing a camera and some manipulators into the abdominal cavity through small punctures in the anterior abdominal wall. Thanks to gas injection ( for diagnostic operations - oxygen, for surgical interventions - carbon dioxide) and the presence of an optical system with lighting, the doctor can directly examine the organs of interest to him. This procedure is carried out in a sterile operating room under general anesthesia.

When diagnosing inflammation of the uterine appendages, laparoscopy is the “gold standard”, as it allows you to quickly establish a diagnosis, determine the degree of structural changes in organs, and also carry out the necessary surgical intervention. In addition, after this study, patients quickly return to their normal activities.

Laparoscopy allows you to identify the following signs of damage to the uterine appendages:

• pus in one of the fallopian tubes;
• fresh ( easily separated) adhesions in the area of ​​the uterine appendages;
• sticky ( fibrous exudate) on the surface of the ovaries and fallopian tubes;
• an increase in the size of the ovaries;
• bleeding of the ovaries when pressed.

Despite all the advantages of laparoscopy as a method for diagnosing oophoritis and other inflammatory diseases of the upper genital tract, its use as a routine examination method is irrational. This is due, firstly, to the rather high cost of the procedure, and secondly, to a number of risks and possible side effects.

Microbiological examination

The following methods for detecting and identifying pathogenic agents exist:

• Bacterioscopic method. Bacterioscopy is based on the study of stained smears obtained by placing the material under study on a glass slide under a light microscope. This method allows you to detect gonococci, chlamydia, trichomonas, and some other pathogens. In addition, microscopy of smears can assess the degree of inflammatory reaction.
• Bacteriological method. The bacteriological method makes it possible to extremely accurately identify pathogens and determine their sensitivity to antimicrobial drugs, but it requires a lot of time. A bacteriological study is carried out by inoculating pathological material obtained from the patient onto special media, which are placed in a thermostat for several days. At the same time, pathogenic bacteria begin to actively multiply, which allows them to be identified in the future by a number of signs.

Treatment of ovarian inflammation

Drug treatment

Drugs used to treat ovarian inflammation

Surgery

Surgery is necessary in the following situations:

• Tuboovarian abscess. The presence of an accumulation of pus in the area of ​​the uterine appendages is a direct indication for surgical intervention, since until this pus is completely drained, drug treatment is not sufficiently effective. To treat this complication, laparoscopic access is preferable, as it is less traumatic and allows for faster recovery after surgery. However, in case of massive accumulation of pus or in the presence of adhesions in the abdominal cavity, a classic laparotomy may be required ( incision of the anterior abdominal wall).
• Peritonitis. An infectious and inflammatory process involving the peritoneum requires immediate surgical intervention, as it is a life-threatening condition. To treat peritonitis, they resort to laparotomy access, as it allows for better and larger sanitization of the abdominal cavity.

Traditional methods of treatment

The following traditional medicine recipes can be used as additional therapy:

• Blackcurrant infusion. To prepare the infusion, you need to mix 4 tablespoons of black currant leaves with 2 tablespoons of yarrow herb, horsetail and barberry, and then pour 2 cups of boiling water and leave for one and a half to two hours. You should drink half a glass every 2 to 3 hours.
• Oat infusion. To prepare the infusion, you need to mix 4 teaspoons of seed oats with 3 tablespoons of birch leaves, 2 tablespoons of peppermint leaves, honey and lemon. The resulting mixture must be mixed and poured with 2 cups of boiling water, then left for 60 minutes. The resulting solution should be consumed 100 ml every 2 – 3 hours.

Prevention of ovarian inflammation

• Timely diagnosis. Timely diagnosis of infectious and inflammatory diseases of the upper and lower reproductive system can reduce the risk of complications.
• Timely examinations. Timely and periodic examinations by a gynecologist make it possible to diagnose diseases at the initial stage, which greatly facilitates and speeds up treatment.
• Protection against sexually transmitted infections. Since the main cause of ovarian inflammation is sexually transmitted infections, it is extremely important to use barrier contraception methods ( condoms), which reduce the risk of transmission of sexually transmitted diseases.
• Treatment of infections of neighboring organs. Timely treatment of infectious foci in organs located near the ovaries can reduce the risk of their involvement in the inflammatory process.
• Healthy lifestyle. To prevent oophoritis, exposure to toxic substances should be avoided ( alcohol, nicotine), cold, exhaustion. It is necessary to eat right and practice physical exercise, as this helps strengthen the immune system and helps normalize the function of the entire body.

Pain in the ovaries - causes, symptoms and what to do?

Bimanual gynecological examination occupies a central place in assessing the condition of the ovaries. Symptoms arising from physiological or pathological processes in the ovaries are usually consistent with physical examination findings. Some ovarian diseases are asymptomatic, so physical examination data may be the only information at the first stage of the examination.
For the right interpretations In order to obtain the results of the study, it is necessary to know the palpation characteristics of the ovaries at different periods of life.

IN premenstrual age ovaries should not be palpable. If they can be palpated, their pathology should be assumed and further in-depth examination should be carried out.

IN reproductive age Normal ovaries are palpable in approximately half of women. The most important characteristics include: size, shape, consistency (dense or cyst-like) and mobility. In women of reproductive age who take oral contraceptives, the ovaries are palpated less frequently, are smaller and more symmetrical than in women who do not use these drugs.

In patients in postmenopausal age, the ovaries are functionally inactive except for the production of small amounts of androgens. The ovaries no longer respond to gonadotropic stimulation and therefore their superficial follicular activity gradually decreases, stopping in most cases within three years of the onset of natural menopause. In women close to the onset of natural menopause, residual functional cysts are more often found. In general, palpable ovarian enlargement in postmenopausal women requires a more critical evaluation than in younger women, since the incidence of ovarian malignancies is higher in this age group.

About 1/4 of all ovarian tumors in the postmenopausal period they are malignant in nature, while in the reproductive age only 10% of tumors are malignant. In the past, the risk was considered so great that detection of any enlarged ovary in the postmenopausal period (the so-called palpable postmenopausal ovary syndrome) was an indication for surgery. The advent of more sensitive diagnostic methods for pelvic imaging has changed routine management. Mandatory removal of minimally enlarged ovaries in postmenopausal women is no longer recommended.

If the patient has natural menopause lasts 3 to years and transvaginal ultrasound reveals the presence of a simple single-chamber cyst less than 5 cm in diameter, further management of such a patient may consist of repeated ultrasound examinations (including transvaginal) to monitor the condition of the cyst. Formations that are larger or have a complex ultrasound structure are best treated surgically.

Functional ovarian cysts- these are not tumors, but rather normal anatomical variations that arise as a result of normal ovarian activity. They can occur as asymptomatic adnexal formations or be accompanied by symptoms that require additional research and, possibly, specific treatment.

When ovarian follicle does not rupture at the end of its maturation, ovulation does not occur and a follicular cyst may occur. The consequence of this will be an extension of the follicular phase of the cycle and, as a result, secondary amenorrhea. Follicular cysts are lined internally with normal granulosa cells, and the fluid they contain is rich in estrogen.

Follicular cyst becomes clinically significant when it reaches a size large enough to cause pain or when it persists for more than one menstrual period. It is not entirely clear why the granulosa cells lining follicular cysts persist beyond the time when ovulation would occur and continue to function during the second half of the cycle. The cyst may enlarge, reaching a diameter of 5 cm or more, and continues to fill with estrogen-rich follicular fluid coming from the thickened layer of fanulosa cells. Symptoms caused by a follicular cyst may include mild to moderate unilateral pain in the lower abdomen and changes in menstrual cycle patterns.

The latter may be the result of both a failed follow-up ovulation, and an excess amount of estradiol produced inside the follicle. Excessive estrogen saturation of the body in the absence of ovulation hyperstimulates the endometrium and causes irregular bleeding. A bimanual gynecological examination may reveal a unilateral, painful, mobile cystic adnexal mass.

Having received such data during the initial examination, the doctor must decide whether further in-depth examination is necessary and decide on treatment. Ultrasound of the pelvic organs is recommended for patients of reproductive age with a cyst size of more than 5 cm in diameter. This study reveals a unilocular simple cyst without signs of blood or soft tissue elements inside and without signs of growth outside. Most patients do not require ultrasound confirmation. Instead, the woman should be reassured and scheduled for a follow-up examination in 6-8 weeks.

Before a gynecological examination, the patient must empty her bladder. Urine samples are tested for sugar, albumin and bacteria. According to indications (for example, with heavy menstruation, fatigue, pallor, the presence of anemia in the previous period), hemoglobin content and hematocrit are determined. Laboratory tests may also include a complete blood count, urinalysis, and measurement of cholesterol and blood lipids.

At general examination determine height, weight, blood pressure, condition of the heart, lungs and lymph nodes. An unusual structure and distribution of hair on the body and face is noted. Enlargement, tenderness, or nodules of the thyroid gland are detected.

Thorough breast examination carried out in a sitting position and lying on the back, noting the degree of their development, symmetry, the presence of seals, pain when pressed, retraction of the skin or nipples. The doctor's hands should be warm and the touch should be soft. During the examination, you can instruct the patient regarding breast self-examination.

Abdominal examination always start with areas distant from the painful area. The doctor methodically feels with a flat palm (without pressing) all quadrants of the abdomen, identifying sensitive areas or lumps. At the same time, he notes the following signs: the presence and size of compactions, their localization, mobility, pain on palpation; presence of scars or sprains; the presence of ascites or other fluids in the abdominal cavity. By palpation, possible soreness of the kidneys, spleen and liver is revealed, and the size of the latter is determined. In case of complaints from the abdominal organs, the presence or absence of bowel sounds is determined using auscultation. In case of pain during palpation, its intensity, localization and possible rigidity of the abdominal wall are assessed. Radiating pain or its occurrence at a distance from the palpable area indicates irritation of the peritoneum.

Gynecological examination usually done last. Unhurried explanations, soft, delicate, but confident behavior of the doctor help relieve the patient’s nervous tension and allow a more thorough examination. After emptying the bladder, the patient should assume a position similar to a stone section (hips and knees bent, buttocks on the edge of the table, legs supported by heel or knee holders). When examining the genitals, the distribution of hair, the size of the clitoris, damage and changes in color of the vulva, discharge, inflammation and the condition of the hymen are revealed. Gently touching the inner thighs reduces the startle response when subsequently touching the genitals. The labia are spread apart with the fingers of one hand. To make the cervix visible and avoid pressure on the urethra, a warmed dilator moistened with water is inserted into the upper part of the vagina and opened. The use of gel as a lubricant is not recommended, as this may affect the results of the Pap test.

Pap test consists of studying exfoliated cells for the diagnosis of both pre-invasive (dysplasia, carcinoma in situ, etc.) and invasive lesions. The test can detect up to 80-85% of cases of malignant cervical tumors and precancerous conditions. During the day before the test, the patient should refrain from douching and using drugs for intravaginal administration. If the sample is unsuccessful or the tumor becomes infected, the sample may give false negative results. In women with malignant endometrial tumors, the test gives a positive result only in half of the cases. At the same time, viral and other infections can be diagnosed and estrogen levels can be assessed.

To take endocervical samples, use an applicator soaked in saline solution with a cotton swab or brush at the end, from which the material is transferred to a glass slide with a slight rotational movement. Scraping from the visible part of the cervix is ​​done around the circumference using a spatula; if necessary, simultaneously obtain a smear from the posterior vaginal vault. Vaginal samples are applied to the same slide as the endocervical smear, or a separate slide is used (at the discretion of the cytologist). Examination of scrapings of the vaginal wall is also carried out in women receiving diethylstilbestrol. Immediately after receiving the sample, fix it with an alcohol solution or aerosol.

Using a mirror, macroscopic changes are revealed; if there is discharge or other symptoms, swabs are taken for further examination. While the patient is pushing, the speculum is gradually removed from the vagina and its walls are examined.

For palpation of the uterus during a two-handed examination, the index and middle fingers of one hand are inserted into the vagina, and the fingers of the other hand are placed on the abdomen. Typically, the uterus feels like a pear-shaped muscular organ with a smooth surface; by moving your fingers from the anterior to the posterior fornix, they determine the location of the uterus, its size, outline, density, mobility and sensitivity. The most difficult thing to determine is the shape and size of the uterus, located retroflexly, when it seems larger than it actually is. Enlarged uterus may be caused by pregnancy, fibroids, adenomyosis, simple hypertrophy, inflammation or cancer. Softening usually occurs during pregnancy, degenerating fibroids or sarcoma, other forms of malignant growth, decreased estrogen levels (with underdevelopment of the uterus or during postmenopause). Shape changes can be caused by the presence of fibroids ranging in size from a few millimeters to tens of centimeters, malignant tumors, abnormalities of the uterus, which are felt as depression of the fundus, or adhesions with other pelvic organs, for example with the ovaries.

For palpation of appendages the fingers of both hands move towards each other; the painful side is examined last. Normally, the ovaries of an adult woman (3x2x2 cm) are not always palpable, especially with a thick or tense abdominal wall. However, this test is very important because it allows us to detect the early stages of cancer, which is especially valuable if there are no symptoms. An increase in the ovaries or the entire mass of the appendages, including tubes, is noted, as well as pathological changes similar to those described above during palpation of the uterus. On the right, you can determine the position of the cecum (by its mobility and the presence of gas). At the same time, the pouch of Douglas behind the uterus is palpated (it is re-examined during a rectal examination). When palpating the vagina, cysts and nodes are revealed.

To find out the status supporting apparatus of the pelvic organs, two fingers lightly rub along the back wall of the vagina; repeating this procedure, determine before and after straining the prolapse of the uterus, as well as signs of cystocele, rectocele and enterocele. Prolapse of the anterior vaginal wall is called cystocele; weakening and prolapse of the posterior wall supported by m. levator ani, - rectocele, and pubescence of the apex of the vagina between the main supporting uterosacral ligaments - enterocele. The latter can also occur after removal of the uterus, when the upper part of the vagina descends to varying degrees.

A rectovaginal examination is performed last to confirm the results obtained by other methods. In this case, the index finger is inserted into the vagina, and the middle finger into the rectum, palpating the uterosacral ligaments, the posterior surface of the uterus and its cervix, the contents of the pouch of Douglas and the periuterine area, identifying the presence of tumor-like formations, compactions or pain. Such a study is especially important with a retroflex position of the uterus. At the same time, possible pathological changes in the rectum on the length of the finger (hemorrhoids, cracks, polyps, seals), as well as the presence of blood in it.

In the posterior third of the vagina, between the uterosacral ligaments (the thinnest layer of the abdominal wall), aspiration biopsy of the liquid contents of the peritoneum is most often performed ( culdocentesis).

After the examination, the doctor discusses the findings with the patient, using diagrams and other illustrative material if necessary, so that she has an idea of ​​her condition and possible treatment methods.

Ed. N. Alipov

“What is a gynecological examination” - article from the section

Ovarian apoplexy is one of the gynecological diseases that cause the clinical picture of an acute abdomen. This dangerous pathology, in the absence of timely medical care, can lead to very serious complications. However, the occurrence of pain in the lower abdomen is not a rare symptom. Almost all women experience pain in this area from time to time, associated with certain phases of the menstrual cycle. But ovarian apoplexy is exactly the disease in which you should pay attention to the pain and seek qualified medical help as early as possible. Knowing the symptoms of ovarian apoplexy helps to diagnose this pathology in a timely manner.

Diagnostic methods and symptoms of ovarian apoplexy

The main clinical symptom of ovarian apoplexy, as well as other gynecological diseases that cause the clinical picture of an acute abdomen, is sudden pain in the lower abdomen. The occurrence of pain in this case is explained by irritation of the receptor field of the ovarian tissue, the effect of spilled blood on the peritoneum, as well as spasm in the ovarian artery basin. In addition to the pain syndrome with apoplexy, a woman is worried about weakness, nausea and vomiting, dizziness and fainting. But depending on the form of the pathology, the clinical picture of ovarian apoplexy may differ slightly.

Symptoms of ovarian apoplexy:

• symptoms of ovarian apoplexy in painful form;
• symptoms of ovarian apoplexy in the hemorrhagic form;
• main methods for diagnosing ovarian apoplexy.

Symptoms of ovarian apoplexy in painful form

The painful form of ovarian apoplexy is observed when hemorrhage occurs directly into the tissue of the follicle or corpus luteum. In this case, there is no bleeding into the abdominal cavity. In this form of the disease, the main symptom of ovarian apoplexy is pain in the lower abdomen, which does not radiate, and may be accompanied by nausea and vomiting. There are no signs of bleeding into the abdominal cavity. Upon examination of the patient, the color of the skin and mucous membranes remains normal, the pulse and blood pressure do not change. On palpation, painful sensations are noted in the iliac region on the right. During a gynecological examination, the uterus is of normal size, the affected ovary may be slightly enlarged and painful on palpation.

Symptoms of ovarian apoplexy in hemorrhagic form

The mild hemorrhagic form of ovarian tissue rupture is clinically very similar to the painful form, but in moderate and severe forms, the symptoms of ovarian apoplexy are somewhat different, since they are associated with intra-abdominal bleeding. The pain syndrome occurs acutely, often appears during physical activity or sexual intercourse, and radiates to the rectum, leg, lower back and external genitalia. The patient is also worried about weakness, dizziness, nausea and vomiting. The patient's skin and mucous membranes are pale, and cold, sticky sweat may occur. Blood pressure is reduced, tachycardia occurs, which is explained by blood loss. Palpation reveals sharp pain in the iliac region; during bimanual gynecological examination, a painful, slightly enlarged ovary is palpated on the side of apoplexy.

Basic methods for diagnosing ovarian apoplexy

To diagnose ovarian apoplexy, the following laboratory and instrumental research methods are used:

• general blood test: moderate leukocytosis in the painful form, decreased hemoglobin levels, leukocytosis in the hemorrhagic form;
• ultrasound examination: a small amount of hypoechoic fluid with a fine suspension in the pouch of Douglas in the painful form, a significant amount of fine and medium-dispersed fluid in the abdominal cavity, with hyperechoic structures of irregular shape in the hemorrhagic form of ovarian apoplexy;
• laparoscopic examination: ovulation stigma is observed - a small spot raised above the surface of the ovary with signs of bleeding, in the form of a cyst of the corpus luteum or the corpus luteum itself with a rupture or defect.

Among all diseases of the female reproductive organs, ovarian cyst occupies a leading position. This is a fairly common pathology that belongs to the group of tumor-like diseases. It occurs most often during reproductive age, but can sometimes be detected in girls or women in menopause. When planning a child, a woman must undergo examination for the presence of tumor-like formations, as they can prevent the onset of a long-awaited pregnancy. And some cystic formations lead to the formation of adhesions in the pelvis, which can make the dream of motherhood impossible.

A cyst is a sac-like formation filled with liquid secretion. The size of the “sac” can vary from a few millimeters to tens of centimeters, when the formation can fill the entire abdominal cavity. It all depends on the type of cyst.

Why do ovarian cysts form?

Tumor-like formations form in the ovaries due to hormonal imbalance, as a result of inflammatory diseases, and blood stagnation in the pelvic area. In this case, a gradual accumulation of fluid occurs, stretching the thin walls of the cyst at the site of formation. Cysts differ from true ovarian tumors in that they grow only due to an increase in the volume of fluid in the cavity. The walls of the formation remain thin. Tumors also increase due to the proliferation of tissue in the wall itself.

Types of ovarian cysts depending on the place of their formation:

• Follicular.
• Corpus luteum cyst.
• Paraovarian.
• Endometrioid.

Follicular cysts are considered the most common. They are diagnosed in more than 70% of cases. The reason for their appearance is the accumulation of fluid in the follicle, which is produced during the menstrual cycle. In a healthy woman, a mature follicle should burst and release an egg. If this does not happen, the follicle grows due to the accumulation of fluid and forms a cyst.

With a corpus luteum cyst, fluid accumulation is noted at the site of the burst follicle. Often accompanied by hemorrhage into the cavity of the formation. Such formations are often detected only during preventive examinations, since they may not produce clinical symptoms and proceed completely unnoticed by the woman. Only a small proportion of patients have complaints of heaviness in the lower abdomen, pain during sexual intercourse, increased urination or flatulence.

These types of tumor formations have a favorable outcome. More often, the doctor chooses a wait-and-see approach for two or three cycles. During this time, cysts can resolve on their own and disappear without a trace.

Paraovarian cysts form on the side of the uterus, between the broad ligament that holds the uterus in the pelvis. This type of formation can reach large sizes, filling the abdominal cavity and causing an enlargement of the abdomen. More often, such a cyst is found in young girls. It can be asymptomatic; occasionally girls are bothered by abdominal pain and are alarmed by an enlarged belly. The disease can occur without disruption of the menstrual cycle. Paraovarian cysts can be complicated by torsion of the pedicle of the formation, causing acute abdominal pain. After removal, the prognosis is favorable.

Endometrioid cysts occur in a condition called endometriosis. With this pathology, islands of tissue growth similar to the endometrium appear. Such lesions can be located on the cervix, ovaries, in the abdominal cavity, walls of the bladder, etc. There are many theories about the origin of the disease, but none have received 100% proof. When endometrioid foci are located in the ovaries and their fusion, they speak of the occurrence of endometrioid cysts. Their characteristic feature is that the secretion is brown in color due to the accumulation of blood. In gynecology, such cysts are called “chocolate cysts.”

The main complaint is abdominal pain, which intensifies during physical work, as well as during sexual intercourse. Menstruation becomes painful, pain appears in the external genitalia and in the pelvic area during sexual intercourse. The earlier a cyst is diagnosed, the greater the chance of successful treatment. Endometrioid cysts can develop into cancer.

Most often, cysts are discovered accidentally during preventive examinations or when planning pregnancy. Less often, women complain of cycle irregularities or abdominal pain. Mandatory and available methods for diagnosing cysts are the following:

• Palpation
• Laparoscopy

During palpation, the doctor feels the uterus and its appendages using a two-handed examination method, when one hand is in the vagina and the second is located on the front wall of the abdomen. For small tumor-like formations, palpation may not yield results. If the size of the cyst reaches several centimeters in diameter, then the doctor can feel the soft, round formation. With a follicular cyst, it is usually located on the side of the uterus on the right or left side. On palpation, the formation is mobile and painless. A corpus luteum cyst is palpated behind the uterus and is sometimes painful.

Paraovarian cysts can be felt above the uterus on the right or left side. This is a smooth formation with limited mobility, can be quite large, and painless.

Cysts in ovarian endometriosis are usually located posterior to the uterus. Their peculiarity is an increase in size after menstruation. Examination of the vagina can be painful due to the presence of adhesions in the pelvis.

Ultrasound examination (ultrasound) of the ovaries allows you to determine the size and number of cysts, their location, wall thickness, and consistency of the contents.

Diagnosis of a cyst using the laparoscopic method is the most informative method. The camera on the laparoscope allows you to view the tumor formation in its natural form. At the same time, the laparoscope can be used to take a biopsy to verify the diagnosis, as well as to perform surgery to remove the cyst. In this case, damage to the soft tissues of the abdominal wall will be minimal.

Possible complications of a cyst and first aid for them

Sometimes complications resemble the picture of an “acute abdomen”, and in this case a woman with an ovarian cyst is admitted urgently to the surgical department. This can happen when the leg of a tumor-like formation is twisted or ruptures. As a result of torsion of the leg, compression of blood vessels and nerve fibers occurs. This causes acute pain and ischemia in the tumor formation. As a result, necrosis of the cystic formation occurs, and peritonitis may develop. A rupture of the wall of the formation is accompanied by an outpouring of its contents into the abdominal cavity with the development of inflammation, which can be fatal if assistance is not provided in a timely manner.

First aid in this case consists of emergency hospitalization of the woman for surgery to remove the cyst or ovary along with the ruptured formation.

The appearance of sharp abdominal pain, decreased blood pressure, increased temperature, and loss of consciousness are symptoms that require calling an ambulance.

Long-term complications include the development of chronic inflammation in the ovaries followed by adhesions, as well as malignancy of the cyst (cancerous degeneration).

First of all, planning a child should begin with a visit to the gynecologist. Before pregnancy, a woman must be sure that everything is in order with her reproductive organs and nothing threatens the health and life of the unborn baby.

If during examinations an ovarian cyst is discovered in a woman or girl, then planning a child should be postponed until complete recovery. Firstly, the presence of cysts can lead to infertility, since often in their presence there is no ovulation and fertilization becomes impossible. Secondly, there is a high risk of developing acute complications of the cyst during pregnancy, and then surgical intervention will be required, which can harm the baby.

medaboutme.ru

Gynecological examination. Gynecological examination

A gynecological examination is carried out in a gynecological chair in the following order:

Examination of the external genitalia - examine the pubis, labia majora and minora, and anus. The condition of the skin, the nature of hair growth, the presence of space-occupying formations are noted, and suspicious areas are palpated. By spreading the labia majora with the index and middle finger of a gloved hand, the following anatomical structures are examined: 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. If there is a history of voluminous formations of the labia majora, 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.

Special gynecological examinations are divided into three types depending on the scope and examination results that they can provide. These include vaginal, rectal and rectovaginal examination. Vaginal and rectovaginal examinations provide significantly more information in their capabilities than rectal examination alone. Most often, a rectal examination is used in girls or in women who are not sexually active.

EXAMINATION OF THE EXTERNAL GENITAL ORGANS

In most cases, one of the signs of the normal structure and undisturbed functions of the reproductive system is, as is known, the appearance of the external genitalia. In this regard, it is important to determine the nature of the pubic hair, the amount and type of hair distribution. Examination of the external and internal genital organs provides significant information, especially in women with menstrual irregularities and infertility. The presence of hypoplasia of the labia minora and majora, pallor and dryness of the vaginal mucosa are clinical manifestations of hypoestrogenism. “Juicy”, cyanotic color of the vulvar mucosa, abundant transparent secretion are considered signs of increased estrogen levels. During pregnancy, due to congestive plethora, the color of the mucous membranes becomes cyanotic, the intensity of which is more pronounced the longer the pregnancy. Hypoplasia of the labia minora, enlargement of the clitoral head, an increase in the distance between the base of the clitoris and the external opening of the urethra (more than 2 cm) in combination with hypertrichosis indicate hyperandrogenism. These signs are characteristic of congenital virilization, which is observed only in one endocrine pathology - CAH (adrenogenital syndrome). Such changes in the structure of the external genitalia with pronounced virilization (hypertrichosis, deepening of the voice, amenorrhea, atrophy of the mammary glands) make it possible to exclude the diagnosis of a virilizing tumor (both ovarian and adrenal glands), since the tumor develops in the postnatal period, and CAH is a congenital pathology that develops antenatally, during the formation of the external genitalia.

For those giving birth, pay attention to the condition of the perineum and genital opening. With normal anatomical relationships of the tissues of the perineum, the genital fissure is usually closed, and only with sudden straining does it open slightly. With various violations of the integrity of the pelvic floor muscles, which usually develop after childbirth, even slight tension leads to a noticeable gaping of the genital fissure and prolapse of the vaginal walls with the formation of cysto and rectocele. Often, when straining, uterine prolapse is observed, and in other cases, involuntary urination.

When assessing the condition of the skin and mucous membranes of the external genitalia, various pathological formations are identified, such as eczematous lesions and condylomas. In the presence of inflammatory diseases, the appearance and color of the mucous membranes of the external genitalia may change dramatically. In these cases, the mucous membrane can be intensely hyperemic, sometimes with purulent deposits or ulcerative formations. All changed areas are carefully palpated, determining their consistency, mobility and pain. After examination and palpation of the external genitalia, they proceed to examining the vagina and cervix in the speculum.

INSPECTION OF THE CERVIX USING MIRRORS

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

For women who are sexually active, vaginal self-supporting speculums from Pederson or Grave, Cusco, as well as a spoon-shaped speculum and a lift are suitable for examination. Folding self-supporting mirrors of the Cusco type are widely used, since their use does not require an assistant and with their help you can not only examine the walls of the vagina and cervix, but also carry out some medical procedures and operations (Fig. 5-2).

Rice. 5-2. Cusco type folding mirror. To examine the patient, select the smallest speculum that allows for a full examination of the vagina and cervix. Fold speculums are inserted into the vagina in a closed form obliquely in relation to the genital slit. Having advanced the mirror halfway, turn it with the screw part down, at the same time move it deeper and spread the mirror so that the vaginal part of the cervix is ​​between the spread ends of the valves. Using a screw, the desired degree of vaginal dilatation is fixed (Fig. 5-3).

Rice. 5-3. Examination of the cervix using a disposable Cusco speculum.

Spoon-shaped and plate speculums are convenient when it is necessary to perform any operations in the vagina. First, a spoon-shaped lower mirror is inserted, pushing the perineum backwards, then parallel to it a flat (front) mirror (“lift”), with the help of which the anterior wall of the vagina is lifted upward (Fig. 5-4).

Rice. 5-4. Inspection of a nascent submucous myomatous node using a spoon-shaped mirror and bullet forceps.

During the examination, using mirrors, the condition of the vaginal walls is determined (nature of folding, color of the mucous membrane, ulceration, growths, tumors, congenital or acquired anatomical changes), the cervix (size and shape: cylindrical, conical; shape of the external pharynx: round in nulliparous women, in the form of a transverse slit in women who have given birth; various pathological conditions: ruptures, ectopia, erosion, ectropion, tumors, etc.), as well as the nature of the discharge.

When examining the vaginal walls and cervix if blood discharge is detected from the external uterine pharynx outside of menstruation, a malignant tumor of the cervix and body of the uterus should be excluded. With cervicitis, mucopurulent discharge from the cervical canal, hyperemia, and erosion of the cervix are observed. Polyps can be located both on the vaginal portion of the cervix and in its canal. They can be single or multiple. Also, when visually assessing the cervix with the naked eye, closed glands (ovulae nabothi) are determined. In addition, when examining the cervix in the speculum, endometrioid heterotopias can be detected in the form of “eyes” and linear structures of cyanotic color. In the differential diagnosis of closed glands, a distinctive feature of these formations is considered to be the dependence of their size on the phase of the menstrual cycle, as well as the appearance of blood discharge from endometriotic heterotopias shortly before and during menstruation.

During a gynecological examination, cervical cancer cannot always be distinguished from cervicitis or dysplasia, so it is necessary to make smears for cytological examination, and in some cases, to perform a targeted biopsy of the cervix. Particular attention is paid to the vaginal vaults: it is difficult to examine them, but space-occupying formations and genital warts are often located here. After removal of the speculum, a bimanual vaginal examination is performed.

BIMANUAL VAGINAL EXAMINATION

The index and middle fingers of one gloved hand are inserted into the vagina. Fingers must be lubricated with a moisturizer. The other hand is placed on the anterior abdominal wall. With the right hand, carefully palpate the vaginal walls, its fornix and the cervix. Any mass formations and anatomical changes are noted (Fig. 5-5).

Rice. 5-5. Bimanual vaginal examination. Clarification of the position of the uterus.

If there is effusion or blood in the abdominal cavity, depending on their quantity, flattening or overhanging of the vaults is determined. Then, by inserting a finger into the posterior vaginal fornix, the uterus is moved forward and upward, palpating it with the second hand through the anterior abdominal wall. Determine the size, shape, consistency and mobility, pay attention to volumetric formations. Normally, the length of the uterus together with the cervix is ​​7–10 cm; in a nulliparous woman it is slightly less than in a woman who has given birth. Reduction of the uterus is possible during infantility, menopause and postmenopause. Enlargement of the uterus is observed with tumors (fibroids, sarcoma) and during pregnancy. The shape of the uterus is normally pear-shaped, somewhat flattened from front to back. During pregnancy, the uterus is spherical, while with tumors it is irregularly shaped. The consistency of the uterus is normally tight-elastic, during pregnancy the wall is softened, and with fibroids it is thickened. In some cases, the uterus may fluctuate, which is typical for hemato and pyometra.

The position of the uterus: tilt (versio), bend (flexio), displacement along the horizontal axis (positio), along the vertical axis (elevatio, prolapsus, descensus) is very important (Fig. 5-5). Normally, the uterus is located in the center of the small pelvis, its bottom is at the level of the entrance to the small pelvis. The cervix and body of the uterus form an angle open anteriorly (anteflexio). The entire uterus is slightly tilted anteriorly (anteversio). The position of the uterus changes when the position of the torso changes, when the bladder and rectum are full. With tumors in the area of ​​the appendages, the uterus is displaced in the opposite direction, and with inflammatory processes - in the direction of inflammation.

Pain in the uterus on palpation is noted only in pathological processes. Normally, especially in women who have given birth, the uterus has sufficient mobility. When the uterus prolapses and prolapses, its mobility becomes excessive due to relaxation of the ligamentous apparatus. Limited mobility is observed with infiltrates of parametric tissue, fusion of the uterus with tumors, etc. After examining the uterus, palpation of the appendages, ovaries and fallopian tubes begins (Fig. 5-6). The fingers of the outer and inner hands are moved in coordination from the corners of the uterus to the right and left sides. For this purpose, the inner hand is transferred to the lateral fornix, and the outer hand to the corresponding lateral side of the pelvis to the level of the uterine fundus. The fallopian tubes and ovaries are palpated between the converging fingers. Unchanged fallopian tubes are usually not detected.

Rice. 5-6. Vaginal examination of the area of ​​the appendages, uterus and fornix.

Sometimes the examination reveals a thin round cord, painful on palpation, or nodular thickenings in the area of ​​the uterine horns and in the isthmus of the fallopian tube (salpingitis). The sactosalpinx is palpated in the form of an oblong formation expanding towards the funnel of the fallopian tube, which has significant mobility. The pyosalpinx is often less mobile or fixed by adhesions. Often, during pathological processes, the position of the tubes is changed; they can be soldered with adhesions in front or behind the uterus, sometimes even on the opposite side. The ovary is palpated as an almond-shaped body measuring 3x4 cm, quite mobile and sensitive. Compression of the ovaries during examination is usually painless. The ovaries are usually enlarged before ovulation and during pregnancy. During menopause, the ovaries become significantly smaller.

If, during a gynecological examination, volumetric formations of the uterine appendages are determined, their position relative to the body and cervix, shape, consistency, soreness and mobility are assessed. In case of extensive inflammatory processes, it is not possible to palpate the ovary and tube separately; a painful conglomerate is often identified.

After palpation of the uterine appendages, the ligaments are examined. Unchanged uterine ligaments are usually not identified. The round ligaments can usually be palpated during pregnancy and when fibroids develop in them. In this case, the ligaments are palpated in the form of cords running from the edges of the uterus to the internal opening of the inguinal canal. The uterosacral ligaments are palpated after parametritis (infiltration, cicatricial changes). The ligaments run in the form of cords from the posterior surface of the uterus at the level of the isthmus posteriorly to the sacrum. The uterosacral ligaments are better identified when examined per rectum. The peri-uterine tissue (parametrium) and serous membrane are palpated only if they contain infiltrates (cancerous or inflammatory), adhesions or exudate.

RECTOVAGINAL EXAMINATION

A rectovaginal examination is mandatory in postmenopause, as well as in cases where it is necessary to clarify the condition of the uterine appendages. Sometimes this method is more informative than standard bimanual examination.

The study is carried out if there is a suspicion of the development of pathological processes in the wall of the vagina, rectum or rectovaginal septum. The index finger is inserted into the vagina, and the middle finger into the rectum (in some cases, to study the vesicouterine space, the thumb is inserted into the anterior fornix, and the index finger into the rectum) (Fig. 5-7). Between the inserted fingers, mobility or cohesion of the mucous membranes, localization of infiltrates, tumors and other changes in the vaginal wall, rectum in the form of “spikes”, as well as in the fiber of the rectal-vaginal septum are determined.

Rice. 5-7. Rectovaginal examination.

Rectal examination. Examine the anus and surrounding skin, perineum, sacrococcygeal region. Pay attention to the presence of scratch marks on the perineum and in the perianal area, anal fissures, chronic paraproctitis, external hemorrhoids. Determine the tone of the anal sphincters and the condition of the pelvic floor muscles, exclude space-occupying formations, internal hemorrhoids, and tumors. Pain or space-occupying formations of the rectouterine cavity are also determined. In virgins, all internal genital organs are palpated through the anterior wall of the rectum. After removing the finger, note the presence of blood, pus or mucus on the glove.

In cases where it is necessary to determine the connection between an abdominal tumor and the genital organs, along with a bimanual examination, examination using bullet forceps is indicated. The necessary tools are spoon-shaped mirrors, a lifter and bullet pliers. The cervix is ​​exposed with speculum, treated with alcohol, and bullet forceps are applied to the front lip (a second bullet forceps can be applied to the rear lip). Mirrors are removed. After this, the index and middle fingers (or only one index finger) are inserted into the vagina or rectum, and the lower pole of the tumor is pushed upward through the abdominal wall with the fingers of the left hand. At the same time, the assistant pulls the bullet forceps, displacing the uterus downwards. In this case, the stalk of the tumor, emanating from the genital organs, is greatly stretched and becomes more accessible to palpation. You can use another technique. The handles of the bullet forceps are left in a calm state, and external techniques are used to move the tumor upward, to the right, to the left. If the tumor comes from the genital organs, then the handles of the forceps are retracted into the vagina when moving the tumor, and with tumors of the uterus (MM with a subserous location of the node), the movement of the forceps is more pronounced than with tumors of the uterine appendages. If the tumor comes from other abdominal organs (kidney, intestines), the forceps do not change their position.

www.medsecret.net

Palpation (feeling) of the abdomen

At the end of the examination, they begin to palpate the abdomen, for which both hands are placed with the palmar surfaces of the fingers on symmetrical places (Fig. 13) and with slow, smooth movements they feel the abdominal integument, their thickness, tension, sensitivity, consistency and divergence of the rectus abdominis muscles, constantly comparing between are symmetrical places. Palpation can be done with one hand (Fig. 14). The hands must be warm, otherwise it will be unpleasantly sore, and in addition, reflex muscle contraction is easily caused, which complicates the study. With deeper palpation, with pliable abdominal walls, you can determine the pulsating aorta lying on the spine, the sacral promontory, and the intestines (the degree of its filling). In the groin area you can find enlarged inguinal lymph nodes, hernial protrusions, tumors of the round uterine ligament and varicose veins. In the upper abdomen, in the hypochondrium, the edge of the liver is found on the right, and the edge of the spleen on the left, provided they are enlarged. Palpation of the kidneys and deep-lying tumors is done with the help of a hand placed under the lower back (Fig. 15). Unchanged internal genital organs cannot be palpated through the abdominal walls.

If there is a tumor in the abdominal wall, its upper and lateral borders, the borders towards the iliac fossae and towards the pelvic cavity, the mobility of the abdominal integument above the tumor and the mobility of the tumor under the abdominal integument are determined.

Sometimes, when palpating the abdomen, especially after abdominal operations, crepitus is felt, which depends on the entry of air into the subcutaneous fat (subcutaneous emphysema). Subcutaneous emphysema is sometimes observed after incorrectly performed subcutaneous infusions, when air is pumped into the subcutaneous tissue along with the infused liquid.

The presence of fluid in the abdomen is determined as follows: one hand is fixed flat on one of the lateral surfaces of the abdomen, the other hand on the opposite side makes a jerking movement towards the hand fixed on the abdomen - a feeling of fluctuation is obtained. It must be remembered that with severe obesity of the abdominal wall, a feeling of false fluctuation (fluctuation of the fatty wall) can be obtained.

When palpating the patient's abdomen, it is necessary to pay attention to sensitivity to pressure in various parts of the abdomen. Pain when palpating the abdomen is observed in inflammatory diseases of the internal genital organs and especially where the peritoneum is involved in the process; a “protective” contraction of the abdominal wall muscles is obtained upon any touch.

By palpating the abdomen, pain points characteristic of inflammatory processes of certain abdominal organs (for example, gall bladder, vermiform appendix) are also determined. As is known, in diseases of the appendix, one of the characteristic signs is pain at McBurney's point, which lies in the middle of the line connecting the anterior superior spine of the right ilium with the navel. Being able to find this daughter is important for recognizing appendicitis. It is also necessary to know the location of the point on the abdominal wall corresponding to the location of the ovary. This point lies on the border between the middle and lower third of the line connecting the navel with the middle of the pupart ligament.

www.medical-enc.ru

Examination of the internal genital organs

After examining the external genitalia, an examination is carried out using mirrors, since a preliminary digital examination can change the nature of vaginal discharge and injure the mucous membrane of the cervix and vagina, which makes the examination results unreliable and makes it impossible to obtain correct diagnostic data when using endoscopic research methods (colposcopy, cervicoscopy, microcolposcopy, etc.).

Inspection of the vagina and cervix is ​​carried out using vaginal speculum (cylindrical, folded, spoon-shaped, etc.). The condition of the vaginal walls (nature of folding and color of the mucous membrane, the presence of ulcerations, growths, tumors, etc.), the fornix and cervix (size, shape - cylindrical, conical; in nulliparous women, the external opening of the cervical canal is round, in those who have given birth - in the form transverse fissure; various pathological conditions - ruptures, erosions, epithelial dysplasia, submucosal endometriosis, eversion of the mucous membrane, tumors, etc.), as well as the nature of vaginal discharge.

For diagnostic purposes, as well as for various manipulations on the cervix, the latter is fixed with bullet forceps, which have one sharp tooth on each branch, or Musot forceps, which have two teeth on each branch, and brought closer to the entrance to the vagina.

Vaginal examination should be combined (bimanual). Spreading the labia with the thumb and index finger of the left hand, the doctor inserts the index (and then the middle) finger into the vagina, paying attention to the sensitivity, the width of the entrance to the vagina, and the elasticity of its walls. With the other hand, he fixes the organ being examined (uterus, appendages) through the abdominal wall or tries to palpate one or another area of ​​the pelvis. The examination is carried out with one index finger or two fingers - the index and middle.

It must be taken into account that the most sensitive places are the clitoris and the anterior wall of the vagina in the area of ​​the urethra, so you should not put pressure on this area; your fingers should slide along the back wall of the vagina. If inserting fingers into the vagina is difficult, it is necessary to move the perineum downwards, and first lubricate the fingers with indifferent fat (vaseline).

By inserting fingers deep into the vagina, the condition of the vaginal mucosa is determined (degree of humidity, the presence of growths, roughness, scars, displacement), the presence of tumors, septum (double vagina); exclude bartholinitis. Through the anterior wall of the vagina, the urethra can be palpated for a considerable distance during its infiltration.

Then, with a finger, they find the vaginal part of the cervix and determine its shape (conical, cylindrical), size, shape of the external uterine os, its opening (in case of isthmic-cervical insufficiency), the presence of ruptures and scars on the cervix after childbirth, tumors. With cervical dysplasia, its surface sometimes seems velvety; ovula Nabothi can be felt in the form of small tubercles. The location of the cervix can sometimes indicate displacement of the uterus.

Subsequently, they proceed to a bimanual (combined) vaginal-abdominal examination, which is the main type of gynecological examination, as it allows one to establish the position, size, shape of the uterus, and determine the condition of the appendages, pelvic peritoneum and tissue.

Bimanual examination is a continuation of vaginal examination. In this case, one hand (inner) is in the vagina, and the other (outer) is above the pubis. During a bimanual examination, it is necessary to feel organs and tissues not with the tips of the fingers, but, if possible, with their entire surface.

First, the uterus is examined. To determine its position, shape, size and consistency, use fingers inserted into the vagina to fix the vaginal part of the uterus, lifting it slightly upward and anteriorly, thereby bringing the fundus of the uterus closer to the anterior abdominal wall. Normally, the uterus is located in the small pelvis along the midline, at the same distance from the symphysis pubis and sacrum, as well as from the side walls of the pelvis. In the vertical position of a woman, the fundus of the uterus is turned upward and anteriorly and does not extend beyond the plane of the entrance to the small pelvis, and the cervix is ​​turned downward and posteriorly. Between the cervix and the body of the uterus there is an angle open anteriorly. However, a number of deviations from this normal (typical) position of the uterus are observed in the form of various kinks and displacements in one direction or another, which forces us to change the research methodology.

Normally, the uterus of an adult woman is shaped like a pear, flattened from front to back; its surface is smooth. When palpated, the uterus is painless and moves in all directions. Physiological reduction of the uterus is observed during menopause. Pathological conditions accompanied by reduction of the uterus include infantilism and uterine atrophy (with prolonged breastfeeding, after surgical removal of the ovaries).

The consistency of the uterus is normally tight-elastic; during pregnancy, the uterine wall is softened, and during fibroids, it is thickened. In some cases, the uterus may fluctuate. This is typical for hematometra and pyometra.

After examining the uterus, they begin to palpate the appendages (ovaries and fallopian tubes). Unmodified fallopian tubes are thin and soft and usually cannot be felt. The ligaments, tissue and appendages of the uterus are normally so soft and pliable that they cannot be palpated.

The sactosalpinx is palpable in the form of an elongated mobile formation expanding towards the funnel of the fallopian tube. The pyosalpinx is often less mobile or fixed by adhesions.

Often, during pathological processes, the position of the fallopian tubes changes; they can be soldered with adhesions in front or behind the uterus, sometimes even on the opposite side.

The ovaries are clearly palpable in women with low nutrition in the form of an almond-shaped body measuring 3x4 cm; they are quite mobile and sensitive. The ovaries usually enlarge before ovulation and during pregnancy. The right ovary is more accessible to palpation than the left.

The peri-uterine tissue (parametrium) and the serous membrane of the uterus (perimetry) are palpated only if they contain infiltrate (cancerous or inflammatory), adhesions or exudate.

When examination through the vagina is not possible (in virgins, with vaginal atresia), as well as in case of tumor formations, a rectal combined examination is indicated.

The study is carried out on a gynecological chair wearing a rubber glove or fingertip lubricated with Vaseline. You must first prescribe a cleansing enema.

A combined rectal-vaginal-abdominal wall examination is indicated if the presence of pathological processes in the vaginal wall, rectum or rectovaginal septum is suspected.

www.medicalj.ru

2018 Blog about women's health.