Traditional medicine

Treatment and examination of the external genitalia. Algorithm for examining the external genitalia

Modern methods of objective examination of gynecological patients include,

Examination methods in gynecology

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

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

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Anamnesis

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

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

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

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

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

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

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

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

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

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

Assessment of general condition

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

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

Gynecological examination

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

Examination of the external genitalia.

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

Inspection using a mirrorcal.

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

Vaginal (bimanual) examination.

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

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

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

Bacterioscopic examination.

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

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

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

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

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

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

Cytological examination.

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

Colposcopy.

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

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

Probing of the uterus.

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

Curettage of the uterine cavity.

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

Cervical biopsy.

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

Puncture through the posterior vaginal fornix.

This is a widespread and effective research method, with which you can confirm with a high degree of confidence the presence of intra-abdominal bleeding, as well as analyze the discharge obtained by puncture.

Ultrasound examination (ultrasound).

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

Hysteroscopy (HS).

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

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

Hysterosalpingography (HSG).

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

Laparoscopy.

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

Computed tomography (CT).

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

Magnetic resonance imaging (MRI).

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

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

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Introduction

The examination of the male genital organs differs from the examination of other organs or systems in that it is not difficult to examine and palpate the male genital organs. However, many doctors perform only the most superficial examination of the genitals. This is a mistake, because a significant number of the most common malignant diseases of the male genital organs can be detected already during a physical examination.

Testicular cancer, the most common type of malignant tumor in men aged 25-30 years, is easily detected by palpation. Prostate cancer can also be easily detected by palpation. In this regard, the male external genitalia must be examined carefully and gently. If significant pathological changes or abnormalities in the development of this area are detected, the patient should be referred to a urologist.

1. Pubic area

Examination of the external genitalia can be performed with the patient in a vertical or horizontal position.

It should be noted the nature of hair growth in the pubic area; in adolescents, characterize the stage of sexual development according to Tanner.

It is necessary to describe obvious pathological changes in the skin in this area (the presence of venereal warts, rashes or signs of scabies). To detect a pathologically enlarged bladder (which indicates inadequate emptying), the suprapubic region should be examined by inspection, percussion and palpation.

2. Penis

The penis consists of two paired, erectile corpora cavernosa, and a smaller, unpaired, erectile spongy body (corpus spongiosum penis), located ventrally in the midline and surrounding the urethra.

The distal part of the penis is covered, like a cap, with a conical-shaped formation - the glans penis. The proximal, rounded edge of the head is called the crown. During examination, the presence or absence of the foreskin (preputium penis) should be noted. In adults, the foreskin should be easily retracted behind the glans, exposing the surface of the inner layer of the foreskin and the glans. Any difficulty indicates the presence of acute or chronic inflammation or scarring of the foreskin.

Phimosis is a situation in which exposure of the head is impossible due to narrowing of the foreskin ring or its scarring. The elasticity of the foreskin tissue in children changes until about 5 years of age, after which it acquires mobility close to that of adults. Any attempt to remove the head of the penis from the preputial sac by force is categorically unacceptable.

Paraphimosis is a situation in which the foreskin cannot be pushed onto the glans penis, as a result of compression and swelling of the glans penis.

Hypospadias is the location of the external opening of the urethra on the ventral surface of the penis.

Epispadias is the location of the external urethral opening on the dorsal surface of the penis.

By lightly squeezing the external opening of the urethra in the anteroposterior direction, you can examine the scaphoid fossa. This technique is especially important in young men, who are more likely to contract a sexually transmitted infection. Any discharge from the external opening of the urethra must be examined bacteriologically to exclude infection.

After examining the distal part of the penis, its shaft should be examined and palpated. Any curvature and asymmetry of the corpora cavernosa and head should be noted. Painful erections due to ventral flexion of the shaft of the penis are often associated with hypospadias.

3. Scrotum

The skin of the scrotum is normally wrinkled and very elastic. If thickening, induration or a decrease in its elasticity appears, the presence of a pathological process in the skin should be suspected. At the same time, some conditions (congestive heart failure, liver failure) may manifest as swelling of the scrotum without any pathological process in the skin.

The size of the scrotum depends on the physique and tone of the underlying muscles (tunika dartos) at rest. The scrotal cavity is divided into two communicating spaces by a median septum. Within each of the mentioned spaces (hemiscrotum) there are a testicle, an epididymis and a spermatic cord. Normally, all of the mentioned formations move freely within the hemiscrotum.

Some benign neoplasms on the skin are observed quite often. Candida albicans infection is very common, located on the scrotum and in the area of the thigh crease. This infection usually occurs in combination with diabetes mellitus, against the background of the use of antibiotics, immunosuppression, and when the skin of the genital organs becomes more “hospitable” for infection with increased humidity and sweating. A clear sign of skin candidiasis is bright red hyperemia. Tinea cruris is also a common fungal infection of the genital skin. This disease causes dark, red-brown spots to appear on the front of the thighs. If in the area of the most active area of inflammation, a thin red spot is visible along its periphery, then you can think about ringworm. Candidiasis and tinea cruris can be treated with conventional antifungal drugs, such as naftifine hydrochloride and imidazole derivatives, although tinea cruris responds poorly to nystatin.

Pathological formations not associated with infection are often observed on the skin. An epidermoid cyst can be located on any part of the body, but its favorite location is the skin of the scrotum. These cysts stain the skin whitish, they are dense, 1-2 cm in diameter, and can be multiple. No specific treatment is required unless the patient seeks treatment for cosmetic reasons. Benign angiokeratomas are also often found. This lesion of the superficial tissues of the scrotum is observed in 20% of adult men and consists of papular hemangiomas measuring 1-2 mm, colored from red to purple. Scattered over the surface of the scrotum. They are usually asymptomatic and do not require treatment. However, if bleeding occurs, electrocoagulation and laser treatment are indicated.

During examination, the testicles must be carefully palpated between the 1st and 2nd fingers. The size, shape and consistency of the testicle should be described. The shape of the testicle is ovoid, its dimensions are about 4 cm or more in length and 2.5 cm in width. The consistency of the testicles is dense and somewhat elastic. They are symmetrical in shape, size and consistency. When examining the testicles in adolescents and men suffering from infertility, it is especially important to characterize the size of this paired organ.

Orchidometry instruments are available (ASSI, Westburn, NY) that can be used to quantify and comparatively assess testicular volume. The testicles must have a smooth surface, they must occupy a certain position in the scrotum. If the testicle is not palpable, then the inguinal canal should be examined to rule out cryptorchidism. The presence of abnormalities on the even, smooth surface of the testicles or detected excess tissue is an indication for urgent referral of the patient to a urologist to exclude a tumor.

When palpating the testicles, difficulties may occur due to an enlarged scrotum; this may be due to the presence of hydrocele (hydrocele). The testicle is covered with visceral and parietal layers of peritoneum (tunica vaginalis testis).

The accumulation of fluid between these two layers leads to the formation of dropsy. Transillumination in a darkened room (using a flashlight or other similar light source) allows you to differentiate a fluid-filled formation (positive transillumination effect) from a dense mass of tissue. Sometimes, upon auscultation of an enlarged scrotum, a peristaltic noise can be detected, which will indicate the presence of an inguinoscrotal hernia.

examination urological genital prostate

5. Epididymis

Examination of the epididymis is directly related to examination of the testicle, since the epididymis is usually located on the upper and posterior surface. The epididymis on both sides are located symmetrically and are accessible to direct palpation. The consistency of the epiidemis is softer than the testicle, and upon palpation it feels like a raised edge of the testis located posteriorly. The epididymis should be examined with extreme caution due to its great sensitivity.

Anatomically, the appendage can be divided into three segments: head, body and tail. Each of the segments corresponds to the upper, middle and lower parts of the formation. Enlargement of the epididymis or pain on palpation is usually associated with an inflammatory process (epididymitis). A cystic formation in the tissue of the epididymis, such as a spermatocele, transmits light and therefore can be detected by transillumination.

6. Spermatic cord

After completing the examination of the epididymis, it is necessary to palpate the spermatic cord. If the patient is in a horizontal position, then it is necessary for him to stand up, since this part of the examination is more convenient to carry out in a vertical position. Typically, palpation begins from the middle of the distance between the outer ring of the inguinal canal and the testicle. It is not difficult to recognize the vas deferens (ductus deferens). It is cord-like in shape and consistency and is a bit like braided electrical wire, but more elastic and slightly larger in diameter. If the vas deferens cannot be palpated, then further special studies are indicated.

Other components of the spermatic cord are felt upon palpation as a small ball of round helminths. Indeed, greatly enlarged and varicose veins of the vas deferens can create such an impression. However, in most cases, a varicocele feels like a more tender formation. For more accurate identification, each spermatic cord is taken between the first three fingers of one hand. After palpation separation of the spermatic cord from other tissues, any increase in its vascular component is clearly felt. The patient is then asked to perform a Valsalva maneuver (take a deep breath, hold your breath, and strain). An increase in the palpable spermatic cord indicates the presence of a small varicocele. If the patient has a pronounced cremasteric reflex, the test result may be less clear. Although varicocele most often develops on the left side, a bilateral process is also quite possible.

Elastic, fleshy inclusions in the tissue of the cord may be a lipoma or, less commonly, liposarcoma. Cystic formations of the cord that can be transilluminated are most often small, local hydroceles. If the patient does not complain, then such findings do not require treatment. If the diagnosis is unclear, the patient should be referred to a urologist. The examination of the scrotum is completed after excluding an inguinal hernia. The second finger of the hand is moved along the surface of the skin of the scrotum and along the spermatic cord proximally to the external inguinal ring. After a clear sensation of the external inguinal ring, the patient is asked to cough and perform a Valsalva maneuver. A feeling of bulging or pushing at this moment indicates the presence of an inguinal hernia. As a result, during the examination of the scrotum, the testicle, its epididymis, the spermatic cord and, finally, the external inguinal ring are sequentially palpated. Testicular enlargement is usually caused by a malignant tumor and requires careful differential diagnosis. Excess tissue in the area of the epididymis of the fovea or spermatic cord is a benign formation, but, nevertheless, requires consultation with a urologist. Patients over 16 years of age should be given instructions for self-examination. Acute pain in the scrotum and other emergency situations will be discussed separately in other sections.

7. Prostate gland

A complete examination of the male external genitalia includes examination per rectum with palpation of the prostate gland. It is recommended that all men over 50 years of age undergo an annual rectal examination to examine the prostate gland, as well as screening for the presence of prostate-specific antigen (PSA). In young men, the prostate gland reaches 3.5 cm in diameter and 2.5 cm in length with a weight of 18-20 g. In configuration, it is similar to a chestnut. The prostate gland is usually enlarged in men over 50 years of age, although the normal size of the gland varies greatly at different ages. Normally, the consistency of the prostate gland is comparable to the consistency of the thenar, when 1 finger is opposed to 5.

During a digital examination of the prostate gland, the patient may be in different positions. The side-lying position (legs bent at the knees and hips and pulled toward the chest) provides an opportunity for a full examination. Another position is possible, when the patient stands with his back to the doctor with a 90° bend at the waist, resting his elbows on the examination table. The doctor puts on a surgical glove and dips the 2nd finger in a water-soluble lubricant. Spreads the patient's buttocks and initially examines the anus. Then the 2nd gloved finger is placed in the anus and gently presses on it. This technique promotes relaxation of the anal sphincter, which allows for rectal examination in the most favorable conditions and allows the doctor to assess the tone of the anal sphincter. After relaxing the latter, the lubricated finger is passed to the vault of the rectum above the prostate gland. The finger should be inserted as deeply as possible to palpate the free posterior surface of the prostate gland.

Typically, the examination begins with palpation of the apex (located closer to the anal sphincter) of the gland and continues at its base. Wide movements of the finger allow the doctor to assess the size and characteristic features of the lateral lobes of the gland and its central groove. When describing the detected changes, their location should be indicated (right, left, apex, base, midline or lateral). The seminal vesicles arise from the base of the gland and are not normally palpable. When palpating the prostate gland, its size is determined. Although urologists tend to express the size of the prostate gland in grams or in relative units from 0 to 4, it is still better to estimate the size in centimeters, specifying its width and length. In addition to the size of the organ, its symmetry should also be characterized. Asymmetry should be highlighted, as should the suspicion of malignant growth, inflammation or infection, which may arise if any irregularities or compaction are detected in the gland. With acute inflammation of the prostate gland, pathological softness (tissue softer than normal) and pain on palpation may be felt. The presence of fluctuation indicates the occurrence of an abscess. Vigorous massage for acute inflammation of the prostate gland is contraindicated.

Before removing the finger, it is necessary to make a wide circular movement along the rectal vault to exclude any pathological changes. After the examination, the patient should be offered a large gauze pad to remove excess lubricant from the perineum. Upon completion of the examination of the prostate gland, discharge from the penis and prostatic juice must be examined microscopically.

8. Urinalysis

Urinalysis is an important part of the urological examination.

In unconcentrated urine, pH, glucose, protein, nitrites and leukocyte esterase are determined by immersing a tester stick into it. After this, the urine sample is centrifuged for 3-5 minutes at a speed of 2500 rpm. The supernatant is poured out, and the remainder is mixed with a small amount of urine remaining in the tube. Then microscopy is carried out at low and high magnification (Table 1-2).

In one field of view (FOF) of the microscope at high magnification, the number of leukocytes, erythrocytes, bacteria, salt crystals, yeast and cylinders is identified and counted. Bacteriological examination of urine is carried out in cases where other urine tests or clinical data suggest that the patient has a urinary tract infection. If the wand test is positive for both nitrates and leukocyte esterase, then this is a strong argument in favor of the patient having a urinary tract infection. The same can be said when 4-5 bacteria are detected in the centrifuged urine residue in the PZ.

9. Self-examination of the scrotum and testicles

Examination of the male external genitalia is an important part of any comprehensive physical examination of a patient presenting with urologic symptoms. It is advisable to carry it out not only with a doctor. Every man aged 20-35 should have his own testicles examined monthly. Every year, a urologist should conduct a digital examination of the rectum in men over 50 years of age, and in those with an unfavorable family history of prostate cancer, in men aged 40 years and older.

Regular (monthly) testicular self-examination is important because testicular cancer often affects young men, but if detected early, the disease is usually curable. The examination is simple and takes a few minutes.

The testicles in the scrotum feel like small, firm, hard-boiled eggs without a shell. On their posterior surface and apex is the epididymis, which is felt separately, like a ridge rising along the posterior surface of the testicle. The appendage has two parts: the body and the tail, which is sometimes felt separately. The spermatic cord is attached to the upper pole of the testicle and extends upward into the inguinal canal. It consists of muscle fibers, blood vessels and the vas deferens. The cord has a spongy structure, with the exception of the vas deferens, which is dense to the touch (like a twig) and feels like “pasta”.

First of all, inspect the entire scrotum and the surface of the surrounding skin, note the presence of any rash, other painful formations, or tumors. Then gently feel the scrotum and its contents. After several such examinations, you will become familiar with the feel of the healthy tissues that make up the testicles, their epididymis, the vas deferens, and any abnormality will be immediately detected. Any changes you see or feel should be brought to the attention of your doctor.

It is advisable to conduct such a self-examination once in a doctor's office so that he can answer any questions that may arise.

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Examination of the cervix using speculum

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, exclude malignant tumor cervix or body of the uterus; at cervicitis mucopurulent discharge from the external uterine os, 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 malignant tumor 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

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

During the examination, using mirrors, the condition of the vaginal walls is determined (the nature of the folds, the color of the mucous membrane, ulcerations, 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 walls of the vagina and cervix, if blood discharge is detected from the external uterine pharynx outside of menstruation, it should be excluded malignant tumor cervix and body of the uterus. At cervicitis mucopurulent discharge from the cervical canal, hyperemia, and cervical erosion 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, endometriotic heterotopias in the form of “eyes” and linear structures of cyanotic color can be detected. 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.

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. More often, a rectal examination is used in girls or in women who are not sexually active.

EXAMINATION OF THE EXTERNAL GENITAL ORGANS

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.

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 a flat (front) mirror (“lift”) parallel to it, 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.

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, endometriotic heterotopias in the form of “eyes” and linear structures of cyanotic color can be detected. 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.

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 identified.

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.

Target: teach how to draw blood from a vein for testing for RW and AIDS.

Equipment:

Disposable syringe;

Sterile tray;

Sterile beads;

Sterile tweezers;

Rubber band;

Napkin or towel (under the tourniquet);

70% ethyl alcohol;

Rubber gloves;

Execution method:

Explain to the woman the need, purpose and progress of the procedure;

Make the woman sit at the table, placing her forearm on the table (you can lie down);

Wear rubber gloves and a mask;

Open the disposable syringe, collect it, releasing the air;

Place in a tray with a cap;

Apply a rubber tourniquet to the patient’s shoulder, placing a napkin between it and the arm;
- Find a vein;
- Treat the puncture site with alcohol twice with different balls, dropping them into a disinfectant solution;

Fix the vein below the intended puncture site with your left thumb;

Enter the vein by piercing the skin;

Draw 5 - 7 ml of blood by slowly pulling the piston towards you;

Remove the tourniquet;

Remove the needle from the vein;

Apply a cotton swab with alcohol to the puncture site, ask the patient to lightly press it for 3 to 5 minutes (prevention of hematoma);

Remove the needle by throwing it into the disinfection tray;

Release blood from the syringe into the test tube slowly along the wall;

Place the test tube in a rack, numbering it;
- Disinfect the syringe;

Make sure that there is no blood coming out of the puncture site and only then allow the patient to straighten her forearm;
- Place the tripod in a container or container for transportation to the biochemical laboratory;
- Remove gloves and wash hands;

Write a direction for research.

5. Algorithm for examining the external genitalia

Indications:- Assessment of physical development.

Equipment:

Gynecological chair;
- Individual diaper;

Sterile gloves.

1. Explain to the woman the need for this study.

2. Ask the woman to undress.

4. Place the woman on the gynecological chair.

5. Perform hand hygiene:

6. Apply 3 - 5 ml of antiseptic to your hands (70% alcohol or thoroughly wash your hands with soap).

Wash your hands using the following technique:

Vigorous friction of palms – 10 sec., repeat mechanically 5 times;

The right palm washes (disinfects) the back of the left hand with rubbing movements, then the left palm washes the right hand in the same way, repeat 5 times;
- the left palm is located on the right hand; fingers intertwined, repeat 5 times;

Alternately rubbing the thumbs of one hand with the palms of the other (palms clenched), repeat 5 times;

Alternating friction of the palm of one hand with the closed fingers of the other hand, repeat 5 times.

7. Rinse your hands under running water, holding them so that your wrists and hands are below elbow level.

8. Close the tap (using a paper towel).

9. Dry your hands with a paper towel.

If it is not possible to hygienically wash your hands with water, you can treat them with 3–5 ml of antiseptic (based on 70% alcohol), apply it to your hands and rub until dry (do not wipe your hands). It is important to observe the exposure time - hands must be wet from the antiseptic for at least 15 seconds.

10. Wear clean, sterile gloves:

Remove rings and jewelry;

Wash your hands in the necessary way (regular or hygienic hand treatment);

Open the top package on the disposable gloves and use tweezers to remove the gloves in the inner package;

Use sterile tweezers to unscrew the upper edges of the standard package, in it the gloves lie with the palm surface up, and the edges of the gloves are turned outward in the form of cuffs;

With the thumb and forefinger of your right hand, grab the inside of the inside edge with your left glove and carefully put it on your left hand;

Place the fingers of the left hand (dressed in a glove) under the back surface of the right glove and put it on the right hand;

Without changing the position of the fingers, unscrew the curved edge of the glove;

Also unscrew the edge of the left glove;

Keep your hands in sterile gloves bent at the elbow joints and raised forward at a level above the waist; Examine the genitals: pubis, type of hair growth, whether the labia majora and minora cover the genital opening.

11. With the first and second fingers of your left hand, spread the labia majora and sequentially inspect: the clitoris, urethra, vestibule of the vagina, ducts of the Bartholinian and paraurethral glands, posterior commissure and perineum.

12. With the first and second fingers of your right hand, in the lower third of the labia majora, first on the right, then on the left, palpate the Bartholin’s glands.

6. Research algorithm using vaginal speculum.

Indications:

Assessment of the condition of the vaginal and cervical mucosa.

Presence of changes in the vagina and cervix.

Taking vaginal swabs.

Equipment:

Gynecological chair.

Individual diaper.

- Sterile gloves.

Vaginal specula.

Foltmann spoon, glass slide.

1. Ask the patient if she has emptied her bladder.

2. Tell the patient that she will be examined on a gynecological chair using gynecological speculum.

3. Clean the gynecological chair with a rag moistened with a 0.5% calcium hypochlorite solution and lay down a clean diaper.

4. Place the patient on a gynecological chair: legs are bent at the hip and knee joints and spread to the side.

5. Put on both hands new disposable or sterile gloves (deeply disinfected), reusable gloves (show the woman that you are wearing sterile gloves).

6. Provide sufficient lighting to allow a complete examination of the cervix.

7. Examine the external genitalia.

8. Take the speculum from the sterile table or container and show it to the woman.

9. Take a spoon-shaped speculum in your right hand, with your left hand (1-2 fingers) spread the labia majora and insert the speculum in the straight size of the small pelvis along the back wall of the vagina to the posterior fornix, expand it to a transverse size. Press the mirror onto the back wall of the vagina (making room for insertion of the lift) and shift the handle of the mirror to your left hand. With your right hand, insert the lift into the vagina in the direct size of the pelvis along the front wall, turn it around, and the transverse size and expose the cervix and vagina.

Insert the two-piece mirror sideways in a closed state at the direct size of the entrance to the small pelvis, first spreading the labia minora with your left hand. Gradually, the mirror is placed in the vagina, unfold it, and place it in the transverse size of the entrance to the pelvis. Open the speculum and expose the cervix.