4. URINALYSIS
1. Urine routine and microscopy
• Physical examination
• Chemical estimation of protein and sugar
• Pus cells,casts
2. Culture and drug sensitivity
• Indications—Pus cells>5
UTI
Cystocele
Urinary complaints
Fistula
3.Urine pregnancy test– for diagnosis of
pregnancy
8. URETHRAL DISCHARGE
Method of collection
• Urethra squeesed against symphysis
pubis from behind forwards using
sterile gloved fingers.
• Discharge through external urethral
meatus collected with sterile swabs
• Swabs—microscopy and culture
9. Vaginal discharge
Method of collection
• Patient not to have vaginal douche
for 24hrs
• Cusco’s bivalve speculum introduced
• Discharge from posterior fornix on
the blade of speculum or cervical
canal taken with a swab
• microscopic examination-Discharge
mixed with normal saline
• culture
10. Identification of organisms in the slide
1.Normal discharge-normal vaginal cells
with doderlein bacilli
2.Trichomonal vaginalis—hanging drop
preparation shows motile flagellated
organisms of varying shape
3.Gardnerella vaginosis(bacterial/non
specific vaginitis)—clue cells,few
inflammatory cells,free floating clumps of
gardnerella,scanty lactobacilli
11. 4.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
12. EXFOLIATIVE CYTOLOGY-
PAPANICOLAOU TEST
• Pap test-Screening test for cancer
• First described by Papanicolaou and Traut in 1943
• Routine gynaecological examination in females,esp
above 35 years
• Yearly screening for 3 years followed by 5 yearly
test
• Uses—
1.screening for cancer
2.identification of local viral infections like herpes and
condyloma accuminata
3.Cytohormonal study
13. 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
• After 30 min,slide air dried and stained with
papanicolaou or Short stain
14. • Modifications
1. Endocervical sampling –endocervix scraped with a cytobrush
and added to the slide
2. Fixative spray—cytospray used in office setup
15. INTERPRETATIONS
• Normal cells
1.Basal cells-small,rounded basophilic with large
nuclei
2.Squamous cells from middle layer –
transparent and basophilic with vesicular nuclei
3.Cells from superficial layer-acidophilic with
characterestic pyknotic nuclei
4.Endometrial cells,histiocytes,blood cells and
bacteria
16. ABNORMAL CELLS
1)Mild dyskaryosis—
• superficial/intermediate squamous cells
• Angular borders,transcluscent cytoplasm
• Nucleus < half of total area of cytoplasm
• Binucleation is common
• CIN-I
18. 3)SEVERE DYSKARYOSIS
• Cells- basal type
round/oval/polygonal/elongated
singly/in clumps
• Nucleus- almost fills the cell
thick,dense,narrow rim of cytoplasm
irregular with coarse chromatin pattern
• CIN III
• Fibre cells- severly dyskaryotic elongated cell
• Tadpole cell- severly dyskaryotic cell with an
elongated tail of cytoplasm
19. 4.Carcinoma in situ 5.Invasive carcinoma
• Parabasal cells with • Cells-single/clusters
increased nucleo- • Tadpole cells
cytoplasmic ratio • Irregular nuclei
• Cytoplasm scanty • Coarse clumping of
• Nucleus- chromatin
irregular,sometimes
multiple
• Chromatin pattern-
granular
20. 6)Koilocytosis
• Nuclear abnormalities due to HPV infection
• Condyloma accuminata
• Cells-perinuclear halo,peripheral conensation
of cytoplasm
• Nucleus-irregularly enlarged,hyperchromatic
with multinucleation
• Disappears with dysplasia
21. • Positive pap smear in genital herpes-giant cells with
viral inclusion bodies
• Silver pap test– pap test+PCR– used for diagnosis of
herpes
22. Reporting system
• normal/abnormal
• Abnormal-CIN/papilloma infection/invasive
malignancy
• Doubtful/inconclusive smear-repeat smear
PAPANICOLAOU CLASSIFICATION-GRADING
I. Normal cells
II. Slightly abnormal-inflammatory change
III. Cells suspicious of malignancy-biopsy indicated
IV. Few Distinctly abnormal,possibly malignant cells
V. Malignant cells seen-numerous
23. Papanicolaou World Health Bethesda System
Class I Normal Within normal limits
Class II AtypiaI inflammatory Inflammation-HPV
Squamous, glandular ASCUS, AGCUS
Class III Mild dysplasia CIN-I Low SIL
Class IV Moderate dysplasia CIN -II High SIL
Severe dysplasia CIN -III
Carcinoma in situ
Class V Squamous cell carcinoma Squamous cell
Adenocarcinoma carcinoma
Adenocarcinoma
24. LIMITATIONS OF PAP SMEAR
• Detect only 60-70% of cervical cancer and 70% of
endomitrial cancer
• Reliability depends on slide preparation and skill
of cytologist
• 10-15% false negative results
• False positive results in presence of infections
• Difficulty if squamocolumnar junction-indrawn as
in post menopausal women(10 day course of
oestrogen cream suggested)
• Postradiation cytology difficult- scarring and
atrophy of vagina
25. Liquid based cytology-cancer
screening
• Plastic spatula after scraping placed in
buffered methanol solution-hemolytic and
mucolytic
• Cells separated by centrifugation and gently
sucked thrrough a filter membrane
• Filter pressed onto a glass slide to form thin
monolayer which is stained
26. CYTOHORMONAL EVALUATION
• Exfoliative cytology
• Non invasive study of epithelium for hormonal
status
• Principle-vaginal epithelium highly sensitive to
oestrogen and progesterone.
oestrogen—superficial cell maturation
progesterone—intermediate cell maturation
• Procedure—scrapings taken from lateral wall
of upper third of vagina
27. INFERENCE
• Normal smear-parabasal,intermediate and
superficial cells
• Oestrogen predominant smear-large
eosinophilic cells with pyknotic nuclei and clear
back ground
• Progesterone predominant smear-
predominantly basophilic cells with vesicular
nuclei and dirty background
• Pregnancy-intremediate and navicular cells
• Post-menopausal smear- parabasal and basal
cells
28. KARYOPYKNOTIC INDEX/MATURATION INDEX
• KPI = Mature squamous cells
Intermediate +basal cells
• Proliferative phase-KPI>25%
• Secretory phase-KPI-very low
• KPI> 10% in pregnancy – progesterone
deficiency
• KPI peaks on the day of ovulation
29. UTERINE ASPIRATION
CYTOLOGY
• Screening test for endometrial
cancer-endometrial sampling
• Sample obtained by
endometreal pipelle/uterine
aspiration syringe or brush
• 90% accuracy with no false
positive findings
• Hormonal studies also done
30. 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
31. CERVICAL BIOPSY
• Confirmatory diagnosis of cervical pathology
• Done at OP if pathology detectable
• Wider tissue excision as in cone biopsy – IP
procedure
33. CULDOCENTESIS
• Transvaginal aspiration of peritoneal fluid from the
pouch of douglas
• Diagnostic procedure-
pelvic abcess
ectopic pregnancy in haematocele
detect malignancy in ascitis with
ovarian cyst
• Instruments- vulsellum forceps,posterior vaginal
speculum,aspiration syringe
34. PROCEDURE
• Patient-lithotomy position
• 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
35. HORMONAL ASSAYS
• RIA,ELISA
• Hormones assayed-
FSH,LH,PRL,ACTH,T3,T4,TSH,progesterone, oestradio
,testosterone,aldosterone,cortisol, hCG,dehydroepia
ndrosterone,andostenedione
• Uses- Diagnosis of menopause,PCOD,prolactinemia
Monitoring treatment regimes in ovulation
induction and AST
36. IMAGING TECHNIQUES-Overview
1.X-RAY
• Plain x ray chest and intravenous urogram- pelvic malignancy esp
cervical cancer,prior to staging.
• Plain x ray pelvis- To locate misplaced IUCD
Visualize bone/teeth in benign cystic teratoma
• Hysterosalpingography-to test tube patency,
Intracavity uterine mass and mullerian anomalies of uterus
• Lymphangiography-to locate lymph nodes involved
in pelvic malignancy
37. 2.ULTRASONOGRAPHY
• Simple,non invasive,painless,safe procedure
• Pelvis and lower abdomen scanned longitudinally and
transversely
• D3 ultrasound-3-D images of pelvic organs
Transabdominal sonography(TAS)-
• Done with transducer operating at 2.5-3.5Mhz
• Bladder full
• Large masses examination –ovarian tumour/fibroid
38. 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
• Difficulty in narrow vagina
Transvaginal colour doppler sonography
• Information regarding blood flow to,from or
within the uterus or adnexa
39. 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,AI,ovum
retrieval
5)sonographic guided oocyte retrtieval
• Ectopic pregnancy-tubal ring in adnexa with
empty uterine cavity
• Evaluation of pelvic mass
40. • 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
41. 3) 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
42. 4) 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
5)Positron emission tomography(PET)
• To differentiate normal tissue from cancerous one based on
the uptake of 18F-FLURO-2DEOXYGLUCOSE
44. 2)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
3)Salphingoscopy and falloposcopy
• Visualise of fallopian tube
• Permits selection of patients for IVF rather than
tubal surgery
45. 4)Culdoscopy
• Visualise pelvic structures via an incision in pouch
of Douglas
5)Cystoscopy
• To evaluate cervical cancer prior to staging
• Investigate urinary symptoms-
haematuria,incontinence and fistulae
6) Proctoscopy and sigmoidoscopy
• To evaluate rectal invovement in genital
malignancy
46.
47. INFERTILITY IN FEMALES
TESTS FOR TUBAL PATENCY
• Hysterosalpingography
• Laproscopic chromotubation
• Sonosalpingography
• Hysterofalloscopy
• Ampullary and fimbrial salpingography
TESTS FOR OVULATION
• Basal body temperature
• Examination of cervical mucus-fern test
• Ultrasound
• Hormonal assays-estrogen and progesterone
48. INFERTILITY IN MALES
• Semen analyisis
• 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