Culdocentesis

Culdocentesis is an invasive diagnostic method, which involves puncturing the posterior vaginal fornix for diagnostic or therapeutic purposes. Given the low availability of minimally invasive and non-invasive diagnostic methods at the primary and secondary levels of medical care, in acute gynecological pathology that requires immediate action, this method is a priority and the most informative. Although culdocentesis has its drawbacks, it is nevertheless necessary to know the basic principles and purposes of such diagnostics.

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Indications for the procedure

Culdocentesis is an invasive procedure that can only be performed by an obstetrician-gynecologist who has the appropriate qualifications for such methods. It must be performed taking into account all the rules of asepsis and antisepsis, so it is mandatory to perform it in an operating room or a clean dressing room. This method is invasive, which increases the risk of possible complications, so its use is limited to those cases where it is difficult to establish a true diagnosis or differentiate similar pathologies. Often, acute gynecological pathologies can be diagnosed using ultrasound. In this case, it is possible to determine free fluid in the retrouterine space, ruptured cysts or other pathologies. If it is not possible to perform an ultrasound of the pelvic organs, which can be in emergency situations when calling a house call or at night, then culdocentesis is the method of choice. Therefore, the indications for culdocentesis are:

1. suspected interrupted ectopic pregnancy and bleeding into the extrauterine space;
2. suspected ovarian cyst rupture;
3. ovarian apoplexy with bleeding;
4. ovarian cancer – to clarify the diagnosis and determine atypia;
5. any suspicion of the presence of fluid in the extrauterine space (Douglas' space) with clinical features of acute abdomen.

In any case, the condition for performing a puncture of the posterior vaginal fornix is the overhang of the posterior fornix during manual palpation and examination in mirrors, as well as a positive symptom of fluctuation or "floating uterus". In this case, you can perform an ultrasound or laparoscopy, which is a less invasive method, but if there is no time for this and there is no opportunity, then this is an indication for culdocentesis.

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Preparation

Preparation for this procedure does not take much time, since the minutes spent matter. As a rule, the procedure is performed under local anesthesia.

First, the external genitals are treated with alcohol and antiseptic. Then, speculums are inserted into the vagina, which allow the intervention field to be limited. The lower lip is pulled down, then the puncture site is marked. This site is located on the posterior vaginal fornix along the midline below the external os. Using a long and thick puncture needle, a puncture is made until a feeling of failure is felt. Then, a piston is attached and the contents are pulled out. Its nature can be used not only to determine the diagnosis, but also to outline further treatment tactics.

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Technique culdocentesis

In addition to determining the indications for this procedure, it is also necessary to decide on the correct tactics so that the intervention is diagnostically justified.

The uterus is located in the small pelvis between the urinary bladder in front and the rectum in the back. Accordingly, there are depressions in these places, which are covered with peritoneum. The space between the uterus and the rectum is the most significant and it is located in such a way that it is below all the cavities, that is, when free fluid gets into the small pelvis, it flows there. This utero-rectal space is also called Douglas's. During culdocentesis, a puncture is performed through the posterior vaginal fornix of this space, since it is here that blood, free fluid, exudate or other pathological fluids can be detected.

Culdocentesis of an ovarian cyst can be performed if there is a suspicion of a rupture of such a cyst in order to differentiate an ectopic pregnancy. In this case, the contents of the puncture in the case of a ruptured cyst will be in the form of serous fluid in the case of a ruptured cyst, and in the case of an ectopic pregnancy or ovarian apoplexy - bloody discharge of varying intensity and volume.

Contraindications to the procedure

Contraindications to culdocentesis are limited to absolute ones, since this method may be necessary to establish a diagnosis. The main contraindications include:

1. inflammatory diseases of the vagina and uterus - invasive intervention can cause not only the spread of the process into the pelvic cavity, but can also significantly worsen the course of the underlying disease;
2. uterine cancer – intervention is contraindicated due to the risk of contact metastasis;
3. suspicion of ongoing bleeding from the pelvic organs in large volumes, which may cause hemorrhagic shock;
4. pregnancy;

These are the contraindications that need to be taken into account, but by weighing the importance and diagnostic value of the procedure itself in each individual case.

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Advantages and disadvantages of culdocentesis

The advantage of culdocentesis is its availability and speed of diagnosis in difficult situations. That is why it can be considered an outdated, but very informative method. But it has its drawbacks, as it is an invasive method and further complications are possible. Inflammatory exogenous processes in the small pelvis can develop, and with this method the rehabilitation period is delayed. Therefore, if it is possible to verify the diagnosis using ultrasound, it is necessary to use the latter method.

The consequences of culdocentesis may be in the form of adhesions in the pelvis, if such a puncture was not isolated. Also, attention should be paid to the condition of the uterus after such a procedure, since a minor hematoma is possible with injury to a medium-sized vessel and prolonged bleeding from it.

The rehabilitation period after culdocentesis usually corresponds to the underlying pathology for which it was performed. That is, if the cause was an ectopic pregnancy, which was confirmed, then rehabilitation should be carried out for at least three months. During this period, you should also abstain from sexual relations. It is recommended to plan the next pregnancy in a year. Care of the genitals does not require special intervention, simple hygienic care with monitoring of the condition and examination by a gynecologist a month after the procedure is needed.

Culdocentesis, although an invasive diagnostic method, is very informative, so it can be used for diagnostics and differential diagnostics of acute gynecological pathology. It is necessary to know the basic conditions for its implementation and indications so that the procedure has as few negative consequences as possible and is diagnostically significant.

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