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Investigation


Investigations in gynaecology

1. Common investigations used in gynaecology

  • Blood values
  • Imaging techniques
  • Urine examination
  • Endometrial sampling
  • Vaginal,cervical swabs
  • Exfoliative cytology
  • Endoscopy
  • Colposcopy
  • Hormonal assays


2.BLOOD ROUTINE Hemoglobin estimation-Excessive bleeding• Total and differential count PID• ESR• PlSerology-VDRL, Australia Antigen, HIV

3. URINALYSIS. Urine routine and microscopy, Physical examination, Chemical estimation of protein and sugar, Pus cells,casts. Culture and drug sensitivity, Urine pregnancy test– for diagnosis of pregnancy

4. Methods of urine collection Midstream collection, Catheter collection.

5. CATHETERIZATION

6. Suprapubic bladder puncture

7. URETHRAL DISCHARGE Method of collection: Urethra squeezed against symphysis pubis from behind forwards using sterile gloved fingers, Discharge through external urethral meatus collected with sterile swabs, Swabs—microscopy and culture.

8. Vaginal discharge Method of collection: Patient not to have vaginal douche for 24hrs, Cusco’s bivalve speculum introduced, Discharge from posterior fornix or cervical canal taken with a swab. Microscopic examination-Discharge is mixed with normal saline culture.

9. Identification of organisms in the slide. Normal discharge-normal vaginal cells with doderlein bacilli, Trichomonal vaginalis—hanging drop preparation shows motile flagellated organisms of varying shape, Gardnerella vaginosis(bacterial/nonspecific vaginitis)—clue cells, few inflammatory cells, free floating clumps of gardnerella, scanty lactobacilli.

10. Vaginal candidasis Vaginal discharge + equal amount of 10% KOH, Caustic potash dissolves all cellular debris, leaving behind more resistant yeast like organisms, Typical hyphae, budding spores or mycelia detected.

11. EXFOLIATIVE CYTOLOGY- PAPANICOLAOU TEST Pap test-Screening test for cancer ervix, LBC Pap smear-screening of cancer PROCEDURE Should be obtained prior to vaginal examination, Patient placed in dorsal position with labia separated, Cusco’s self retaining speculum inserted without lubricants. Cervix exposed , squamocolumnar junction scraped with concave end of Ayre’s spatula by rotating all around, Thin smear is prepared on a glass slide and fixed by equal amounts of 95% alcohol and ether Liquid based cytology-cancer screening Plastic spatula after scraping placed in buffered methanol solution-hemolytic and mucolytic, Cells separated by centrifugation and gently sucked through a filter membrane, Filter pressed onto a glass slide to form thin monolayer which is stained

12. ENDOMETRIAL BIOPSY Most reliable method to study endometrium, Endometrial tissue obtained by curretage and subjected for histopathology. Indications, suspected cases of Endometritis ,endometrial cancer, Infertility, Abnormal menstrual bleeding, Diagnosis of corpus luteal phase defect

13. CERVICAL BIOPSY Confirmatory diagnosis of cervical pathology.

14. COLPOSCOPY Colposcope-binocular microscope- 10-20 X, Use-colposcope directed biopsy colposcopic examination of cervix and vagina

15. CULDOCENTESIS, Transvaginal aspiration of peritoneal fluid from the pouch of douglas.
PROCEDURE Patient-l ithotomy position, Hold Posterior lip of cervix-downwards and forwards with vulsellum forceps, Speculum-retracts posterior vaginal wall, Area disinfected, Aspiration syringe inserted into the pouch and aspirated, Done best in OT under full asceptic precautions and to proceed laproscopy/laprotomy if indicated
16. HORMONAL ASSAYS FSH, LH, PRL, ACTH, T3, T4, TSH, progesterone, oestradio, testosterone, aldosterone, cortisol, hCG, dehydroepia ndrosterone,andostenedione

17. IMAGING TECHNIQUES-Overview
1. X-ray
2 ULTRASONOGRAPHY Simple, non invasive, painless, safe procedure, Pelvis and lower abdomen scanned longitudinally and transversely, D3 ultrasound-3-D images of pelvic organsTransabdominal sonography(TAS), Done with transducer operating at 2.5-3. 5Mhz• Bladder full, Large masses examination –ovarian tumour/fibroid.
3 Transvaginal sonography (TVS) Probe placed close to organ, High frequency waves used-5-8MHz, No need of full bladder, Detailed evaluation of pelvic organs possible, Better image resolution but poor tissue penetration.

18. Diagnostic USG in gynaecology Infertility workup 1) folliculometry-measurement of ovarian follicle diameter 2) measurement of endometrial thickness 3) evidence of ovulation-internal echoes and free fluid in pouch of douglas 4) timing of ovulation-helps in ovulation induction 5) sonographic guided oocyte retrtieval, Ectopic pregnancy-tubal ring in adnexa with empty uterine cavity, Evaluation of pelvic mass.

19. Oncology-to assess vascularity of tumour and confirm malignancy, Endometrial study in DUB, Diagnose uterine pathology-fibroids, adenomyosis, Location of misplaced IUD, Falloposcopy-to study medial end of tube, Diagnose endometriosis, To study ovarian pathology-PCOD, ovarian cyst, tumour, Congenital anomalies of uterus• Diagnose adnexal mass.

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

21. Magnetic resonance imaging, Well established cross sectional imaging modality, High soft tissue contrast resolution without air/bone interference, Limitations-cost, time, availability. Indicated only when a sonar or CT fails to detect a lesion or to differntiate post-tratment fibrosis or tumour.
Positron emission tomography (PET), To differentiate normal tissue from cancerous one based on the uptake of 18F-FLURO-2DEOXYGLUCOSE

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

23. Hysteroscopy Visualise endometrial cavity, Diagnostic uses 1. Unresponsive irregular uterine bleeding 2. Congenital uterine septum 3. Missing threads of IUD 4. Intrauterine adhesions 5. Endometrial polyps/ malignant growth Salpingoscopy and falloposcopy, Permits selection of patients for IVF rather than tubal surgery.

24. Culdoscopy Visualise pelvic structures via an incision in pouch of Douglas
Cystoscopy, To evaluate cervical cancer prior to staging, Investigate urinary symptoms-haematuria, incontinence and fistulae Proctoscopy and sigmoidoscopy, To evaluate rectal invovement in genital malignancy.

25. INFERTILITY IN FEMALES
TESTS FOR TUBAL PATENCY, Hysterosalpingography, Laproscopic chromotubation, Sonosalpingography, TESTS FOR OVULATION, Basal body temperature, Examination of cervical mucus-fern test, Ultrasound, Hormonal assays-estrogen and progesterone.

26. INFERTILITY IN MALES Semen analysis, Post-coital test-Sim's test, Sperm penetration test, Semen-cervical mucus contact test, Urine examination, Patency of vas-vasogram, Testicular biopsy, Hormonal assays- FSH, LH, testosterone, prolactin, Chromosomal study, Immunological tests-ELISA, RIA, Ultrasound scanning

27. PRE-OPERATIVE INVESTIGATIONS IN GYNAECOLOGY Complete blood count, Urinalysis, FBS, PPBS, BT, CT, Blood group and Rh factor, RFT, LFT, Serology- VDRL Serum electrolytes-Na, K, Cl, HCO3, Chest radiograph, ECG, IVP.

28. Tumour markers 1. CA-125, Adenocarcinoma ovary 2. CEA, α-fetoprotein, β-hCG—Ovarian teratomas, Bacterial examination of genital tract 1.Smear and microscopy 2. Culture 3. PCR

29. Uroflowmetry Most often your doctor will recommend an uroflowmetry test if you report symptoms of slow urination or urination difficulties. The test might also be used to determine how well your urinary tract is functioning. By measuring the average and maximum rates of your urine flow, the test can estimate the severity of any blockage or obstruction. It can also help identify other urinary problems, such as a weak bladder.

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