culdocentesis.pptx

Brief info on CULDOCENTESIS

1. CULDOCENTESIS

2. Contents Keywords Meaning and Procedures Diagnosis and Causes Clinical relevance

3. KEYWORDS Recto uterine pouch: The  rectouterine pouch ,  pouch of Douglas , or  rectovaginal pouch  is the extension of the peritoneum between the rectum and the posterior wall of the  uterus  in the human female. Vesicouterine pouch: The vesicouterine pouch is a fold of  peritoneum  over the  uterus  and the bladder, forming a pelvic recess. Recess:   a small, empty space or cavity. Contraindications: Anything (including a symptom or medical condition)  that is a reason for a person to not receive a particular treatment or procedure because it may be harmful

4. INTRODUCTION In Males, the space is called the Rectovesical pouch is the forward reflection of the peritoneum from the middle third of the rectum to the upper part of the bladder in males. The  rectovesical pouch  is the pocket that lies between the  rectum  and the  bladder  in human. In  women , the  uterus  lies between the rectum and the bladder. Therefore, women do not have a rectovesical pouch, but instead have a  rectouterine pouch  and  vesicouterine pouch .

5. Female Pelvic Region Male Pelvic Region

6. CULDOCENTESIS Diagnostic technique Overview Culdocentesis is a procedure in which peritoneal fluid is obtained from the cul de sac of a female patient. It involves the introduction of a spinal needle through the vaginal wall into the peritoneal space of the pouch of Douglas. Prior to the wide availability of ultrasonography, it was considered particularly valuable in the diagnosis of ectopic pregnancy, at a time when 97% of ectopic pregnancies ruptured before diagnosis. Anatomy The pouch of Douglas (recto-uterine pouch) is formed by reflection of the peritoneum between the rectum posteriorly and the posterior surface of the uterus anteriorly. The pouch often contains small intestine and a small amount of peritoneal fluid. It is the most dependent intraperitoneal space in both the upright and the supine position. Blood, pus, and other free fluids in the peritoneal cavity pool in the pouch because of its dependent location

7. INDICATIONS Culdocentesis may be used to evaluate women with pain in the lower abdomen/pelvis to determine whether intraabdominal fluid is present and, if present, to reveal the nature of the fluid (eg, serous, purulent, bloody). Thus, the procedure can be helpful in evaluating women with a suspected ruptured ovarian cyst, pelvic inflammatory disease, or ruptured ectopic pregnancy. Contraindications See the list below: Pelvic mass, including  ovarian tumors ,  tubo-ovarian abscesses , appendiceal abscesses, and pelvic kidney Fixed retroverted uterus : Mobile retroverted uterus may be manipulated out of the way by lifting on the cervix with a tenaculum . Coagulopathy Prepubescence: This limitation is suggested on the basis of anatomy, as the procedure would be difficult to perform through a small prepubertal vagina. Noncooperative patient

8. Anesthesia Lidocaine (1-2%) with epinephrine is injected into the vaginal mucosa of the posterior fornix in the midline about 1 cm inferior to the point at which the posterior vaginal wall joins the cervix. Equipment : Bivalve vaginal speculum (Graves or Pederson ), Tenaculum or Allis clamp, Ring forceps, Spinal needle, 18 gauge (ga), Sterile swabs or sponge, Monsel solution (ferric subsulfate ) for hemostasis, Butterfly needle, 19 ga, Needle, 25 ga, 1 inch, Syringe, 20 mL, Antiseptic (eg, povidone-iodine solution [ Betadine ]), Lidocaine (1-2%) with epinephrine, Sterile gloves, Specimen container, Light source

9. INSTRUMENTS FOR CARRYING OUT A CULDOCENTESIS

10. TECHNIQUES The procedure should start with a bimanual examination to assess the adnexa, cervix for cervical motion tenderness, uterus including uterine position, and for cul-de-sac mass or tenderness. Then a speculum exam should be performed by lubricating a speculum and inserting it into the vagina. Foerster sponge forceps should be used to introduce iodine soaked gauze to cleanse the cervix and posterior fornix. Apply a tenaculum or Vulsellum forceps to the lower lip of the cervix, be sure to warn patients about potential cramps during this part of the procedure. Move the tenaculum to expose the posterior fornix of the vagina. Usually, this involves moving the cervix forward and anterior. Anesthetize the mucosa about 1 cm below the posterior rim of the cervix with lidocaine. Use an 18 gauge 10 cm long needle attached to a 10 mL syringe with 2 to 3 mL of air or sterile saline and insert the needle tip 1 cm below where the cervix ends in the posterior fornix. Advance the needle 3 to 4 cm and inject the air or saline. If there is resistance when injecting the air or saline, reposition the needle until there is no resistance felt. The needle should enter the Pouch of Douglas (rectouterine pouch or cul-de-sac). Aiming the needle towards the sacrum and away from the uterus may help with positioning. Lastly, attempt to aspirate. The procedure should be stopped if three attempts produce no fluid return.

11. POSITIONING Allow the patient to walk or sit up for a short time prior to the procedure to allow gravity to help bring the peritoneal fluid to the cul de sac. Place the patient in dorsal lithotomy position with the feet in stirrups. Elevating the head of the bed helps the intraperitoneal fluid gravitate to the retroperitoneal pouch for easier aspiration.

12. Assessment Normal culdocentesis result: A normal culdocentesis result in the absence of pathology should yield only 2-4 mL of clear to straw-colored peritoneal fluid. Non-diagnostic result: A dry tap (return of no fluid) has no diagnostic value; the needle may simply not have found the pool of fluid. Non-diagnostic results are returned in 15% of culdocentesis procedures. Positive Results: A positive tap is one in which more than 2 mL of nonclotting blood is obtained. Absolute volume may be related to the needle position or the rate of bleeding, so larger amounts of blood have no particular significance. Approximately 82-95% of ectopic pregnancies display nonclotting blood on culdocentesis . A positive culdocentesis result can also occur in nonpregnant women (eg, retrograde menstruation). Negative result A culdocentesis is considered negative when the aspirated fluid is pus, cystic, or straw-colored.

13. Culdocentesis Fluid  Condition and Suggested Differential Diagnosis  Clear, serous, straw-colored (usually only a few mL) Normal peritoneal fluid Large amount of clear fluid Ruptured or large ovarian cyst (fluid may be serosanguineous); pregnancy may coexist Ascites Carcinoma Exudates with PMN* leukocytes Pelvic inflammatory disease Purulent fluid Bacterial infection Tubo-ovarian abscess with rupture Appendicitis with rupture Diverticulitis with perforation

14. ECTOPIC PREGNANCY AND CULDOCENTESIS Culdocentesis has been used routinely in the evaluation of ectopic pregnancy. A pregnancy in which the fertilised egg implants outside the uterus. The fertilised egg can't survive outside the uterus. If left to grow, it may damage nearby organs and cause life-threatening loss of blood. Depending on the type of fluid withdrawn, the result interpretation. Non clotted blood indicates active bleeding from a ruptured  ectopic pregnancy . Clotting blood indicates blood from the vein or artery during an aspiration.

15. What are the complications of the culdocentesis procedure? The complications of culdocentesis procedure include: Puncture/injury of adjacent organs Infection Bleeding A false result Leakage of fluid into the uterus

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