Digital Pelvic Examination Research Articles

Bucket-handle cervical tear at term following oxytocin-induced vaginal delivery: a case report

BackgroundA bucket-handle cervical tear, a laceration of the anterior or the posterior lip of the cervix so that it hangs like the handle of a bucket, is the rarest type of cervical laceration. Our case represents such a serious cervical laceration.Case summaryA 28 year-old para 2 (both vaginal deliveries) Ethiopian mother presented at term with prolonged rupture of membrane. After 8 hours of oxytocin induction, a bucket-handle cervical detachment was detected at the time of her vaginal delivery, up on digital pelvic examination. Delivery of the baby was noted to be through the cervical tear, not the cervical opening. Cervix was amputated at the level of the cervical tear, 4 days after a failed initial repair surgery.ConclusionWhen bucket-handle cervical tear is encountered, a thorough clinical evaluation of the viability of the cervical tissue and feasibility of a repair procedure should be made during the first surgery. If the cervical detachment is near total, as in our case, we recommend amputation of the hanging cervical tissue from the outset.

High-density surface electromyographic assessment of pelvic floor hypertonicity in IC/BPS patients: a pilot study.

To assess the feasibility of objectively assessing pelvic floor hypertonicity (PFH) in women with interstitial cystitis/bladder pain syndrome (IC/BPS) using an intra-vaginal high-density surface electromyography (HD-sEMG) probe. Seven female subjects (mean age 44 ± 13years) with a prior diagnosis of IC/BPS were recruited. A full digital pelvic examination was administered to identify hypertonic muscles. Intra-vaginal HD-sEMG was acquired during rest. Root-mean-squared (RMS) amplitude during rest was calculated for each channel to define a hypertonicity index and hypertonic zone. Innervation zones (IZs) were identified from the bipolar mapping of decomposed HD-sEMG signals and summarized into an IZ distribution mapping. Of the seven subjects recruited, five had normal pelvic floor muscle tone and two exhibited hypertonicity upon muscle palpation. Subjects with PFH demonstrated a higher hypertonicity index (12.6 ± 3.5 vs. 4.5 ± 1.2) in sessions 1 and 2. The hypertonic zone defined by the 64-channel RMS mapping coincided with the digital pelvic examination findings. The corresponding IZs were localized for each motor unit. The hypertonicity indices between two consecutive sessions were well correlated (CC = 0.95). This study represents the first effort to employ intra-vaginal HD-sEMG to assess PFH in women with IC/BPS. Our results demonstrate the feasibility of HD-sEMG to provide a quantitative diagnosis of PFH and the precise localization of hypertonic muscles and IZs. The proposed HD-sEMG-based techniques provide promising tools for clinical diagnosis and treatment of PFH, such as the personalized guidance of BoNT injections.

Prediction of Pouch of Douglas Obliteration: Point-of-care Ultrasound Versus Pelvic Examination

To evaluate the point-of-care preoperative transvaginal ultrasound (TVUS) sliding sign in comparison with palpation of a nodule on digital pelvic examination for the prediction of pouch of Douglas (POD) obliteration. Analysis of data from a prospective data registry (Canadian Task Force classification II-2). A tertiary referral center. Women with suspected endometriosis who had preoperative pelvic examination and point-of-care TVUS followed by laparoscopic surgery between August 2015 and December 2016. Women were preoperatively assessed for the prediction of POD obliteration with pelvic examination for a nodule and point-of-care TVUS uterine/cervix sliding sign. The study included 269 women, 15.2% (41/269) of whom had POD obliteration at the time of surgery. A preoperative negative sliding sign had a sensitivity of 73.2% (95% confidence interval, 57.1%-85.8%) and a specificity of 93.9% (95% CI, 89.9%-96.6%) in the prediction of POD obliteration compared with preoperative palpation of a nodule on pelvic examination, which had a sensitivity of 24.4% (95% CI, 12.4%-40.3%) and a specificity of 93.4% (95% CI, 89.4%-96.3%). The difference in sensitivity was statistically significant (McNemar test, p <.001). A negative sliding sign was also associated with longer operating times and more difficult surgery including the need for ureterolysis. The point-of-care TVUS sliding sign showed significantly improved sensitivity compared with palpation of a nodule on pelvic examination for the prediction of POD obliteration. Therefore, the point-of-care TVUS sliding sign improves the preoperative assessment of POD disease and thus may lead to more optimal surgical planning in women with suspected endometriosis.

Objective diagnosis of arrested labor on transperineal ultrasound.

Recent developments in transperineal ultrasound imaging of the pelvis have prompted trials to objectively evaluate labor progression for labor management. We evaluated the accuracy of transperineal ultrasound in diagnosing arrest of labor. Transperineal ultrasound and digital pelvic examinations were performed simultaneously in 63 term laboring patients (singleton fetuses in cephalic presentation). We analyzed a total of 216 ultrasound images (Sonography Volume Computer Aided Display Labor [Sono VCAD Labor®] installed in Voluson E8 ultrasound). We examined the correlation between the three ultrasound parameters head direction (HD), progression distance (PD), and progression angle (PA), and digital pelvic examination findings during labor in a transvaginal delivery group and an arrested labor group. The coefficient of correlations between HD/PD/PA and cervical dilation/fetal station were 0.667/0.657/0.706 and 0.667/0.751/0.803, respectively. The three parameters had strong correlations with digital pelvic examination (P < 0.05). In the 11 cases (17%) of cesarean section due to arrested labor, the position of the fetal head was visually unchanged on sequential ultrasound images. According to receiver operating characteristic curves, the significant cut-offs for HD, PD, and PA for arrested labor were 105° (P = 0.048), 35 mm (P = 0.048), and 120° (P = 0.001), respectively. Transperineal ultrasound imaging is helpful for objective evaluation of labor progression and the diagnosis of arrested labor.

The pelvic floor muscle hyperalgesia (PFMH) scoring system: a new classification tool to assess women with chronic pelvic pain: multicentre pilot study of validity and reliability

ObjectiveThe contribution of pelvic floor muscle tenderness to chronic pelvic pain (CPP) is well established in the literature. However pelvic floor muscle hyperalgesia (PFMH) is often missed during vaginal examination of women with CPP. To our knowledge criteria for diagnosing PFMH has not been established or validated so far. The aim of this study is to assess the validity and reliability of the PFMH scoring system. Study designWomen with and without PFMH were recruited prospectively. Digital pelvic examination was performed to detect any pain. All women were asked to report of any discomfort or pain evoked by digital palpation of the PFMs and to rate the severity of pain/discomfort as none (grade 0), mild (grade I) moderate (grade II) or severe (grade III). All women were also asked to describe the severity of the pain/discomfort using a visual analogue scale (VAS).Following examination a PFMH score was given according to each patient's reactions. Intra-observer and inter-observer reliability was assessed. Construct and content validity was also determined. Results111 (44 symptomatic and 67 controls) were recruited. Intraobserver reliability had ICCs between 0.426 and 0.804. Interobserver reliability had ICCs between 0.724 and 0.917. There was a good correlation between PFMH scores and VAS scores (rho 0.994, p<0.01). Total scores between symptomatic and controls were significantly different (p<0.01 Mann–Whitney U test). ConclusionThe PFMH scoring system is a simple, reliable, valid and easy screening tool for in the assessment of women with CPP.

Intrapartum sonography for fetal head asynclitism and transverse position: sonographic signs and comparison of diagnostic performance between transvaginal and digital examination

Objective: The primary goal of this study was to determine the ultrasonographic signs of asynclitic and transverse head positioning. In addition, we compared the performance of intrapartum ultrasound to vaginal digital examination. Material & Methods: 150 women were evaluated by 2D transabdominal and translabial ultrasound (US) to detect the asynclitic and deep transverse positions. Transvaginal sterile digital examinations were performed immediately after each intrapartum US assessments, the examinations were repeated at intervals of 45–90 minutes. Examiners were blinded to each other’s findings (clinical or sonographic). Data were reviewed and analyzed by an independent reviewer. Results: The efficacy of digital examination was significantly lower than US evaluation for the detection of either transverse position or asynclitism. The most frequent transverse position was the left one, while the most frequent asynclitism was the anterior one. Conclusions: Digital pelvic examination for detection of fetal head transverse position during labor is inferior to US, especially in the deep transverse positioning, where caput succedaneum occurs and reduces the diagnostic accuracy of vaginal digital examination. The US examination leads to early detection of persistent transverse position allowing for earlier timing and optimal technique for the operative vaginal delivery. We describe two signs for diagnosing asynclitism. The “squint sign” and the “sunset of thalamus and cerebellum signs” are two simple US signs allowing detection of anterior and posterior asynclitism.

Hemoperitoneum assessment in ectopic pregnancy

Objective To identify routine clinical, ultrasound, and biologic criteria to assess the volume of hemoperitoneum in women with ectopic pregnancy (EP). Methods Except for patients with hemodynamic shock, all women assigned to surgical laparoscopic treatment for confirmed EP at Poissy Saint Germain en Laye Hospital between January 2004 and December 2007 were included in the study. The patients underwent abdominal and digital pelvic examination, and standardized ultrasonography. Ordered logistic regression analysis was performed to select criteria associated with an increase in hemoperitoneum. The diagnostic accuracy of each variable was then calculated for different hemoperitoneum cut-off values. Results The study included 215 patients. Pelvic pain of 4 or above on a numeric rating scale (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3–4.1), abdominal guarding or rebound tenderness (OR, 4.6; 95% CI, 2.0–10.8), hemoglobin under 10 g/dL (OR, 12.2; 95% CI, 4.2–35.8), presence of fluid at transvaginal ultrasound (OR, 3.6; 95% CI, 1.4–9.2), and fluid in Morison pouch at abdominal ultrasound (OR, 5.6; 95% CI, 2.0–15.9) were found to be independently associated with hemoperitoneum. Conclusion Both clinical examination and standardized ultrasonography were found to be useful for accurate evaluation of hemoperitoneum in patients presenting with EP.

Transvaginal ultrasound of cervical length and its correlation to digital cervical examination, time to spontaneous labor and mode of delivery

The objective of this study was to determine if transvaginal ultrasound (TVUS) examination of cervical length correlates to digital pelvic examination and if it can predict time to and mode of delivery in term pregnancies. We conducted a prospective cohort study of 726 consecutive non-laboring, term pregnant women presenting to University-based antenatal testing unit between 1 July 2001 and 31 March 2002. Subjects underwent a TVUS for cervical length followed by a digital cervical examination by a physician blinded to the results of the ultrasound. Linear regression analysis was used to correlate the findings of cervical length by ultrasound with cervical dilatation and effacement by digital examination. In 726 women, the relationship between TVUS cervical length and cervical dilatation and effacement measured digitally were found to be significantly related (p < 0.001), but weak, with a 15 and 23% goodness of fit, respectively, based on the linear model. Using multivariate logistic and linear regression, respectively, TVUS cervical length predicted mode of delivery but did not predict time to spontaneous labor. Digital measurement of cervical dilatation was predictive of time to spontaneous labor. There is a statistically significant correlation between TVUS measurement of cervical length and digital cervical exam though the correlation is weak. TVUS measurement of cervical length was predictive of mode of delivery while controlling for digital cervical examination, parity and time to spontaneous labor. Digital cervical dilatation was predictive of time to spontaneous delivery.

What is the most reliable ultrasound parameter for assessment of fetal head descent?

The aims of this study were, first, to establish the agreement between digital and ultrasound assessment of occipital position and, second, to evaluate the repeatability of the measurements of head direction, angle of the middle line, progression distance and angle of progression in women in the second stage of labor. Digital examination and then transabdominal ultrasound examination was performed on 50 women in the second stage of labor to determine the fetal occipital position. We also obtained three-dimensional (3D) blocks of the fetal head by transperineal sonography, and two experts in 3D ultrasound measured head direction, angle of the middle line, progression distance and angle of progression. Intraclass correlation coefficients with 95% CIs, and Bland-Altman analysis, were used to evaluate intraobserver and interobserver repeatability of measurements. The fetal head position, determined by ultrasound examination, was occiput anterior in 33 (66%) cases and occiput lateral in 17 (34%) cases. Vaginal digital examination failed to identify the correct fetal head position by more than 45° in 33 (66%) cases. All four 3D ultrasound measurements were reproducible but the progression angle had the highest intraclass correlation coefficient for the same observer (0.94; 95% CI, 0.90-0.97) and for two different operators (0.84; 95% CI, 0.73-0.91). The progression angle was also the measurement for which smaller limits of agreement (LOA) were found in the Bland-Altman test, performed to calculate the intraobserver (bias 0.9; LOA, - 9.2 to 11.1%) and interobserver (bias 1.5; LOA, - 15.4 to 18.3%) variability. Digital pelvic examination for determining the fetal head position during labor is not accurate. The most reproducible of the 3D measurements for progression of the fetal head in labor is the progression angle.

Metastasierendes Adenokarzinom bei unbekanntem Primärtumor

Metastatic adenocarcinoma without demonstration of the primary tumour was diagnosed within a period of 42 months in 13 women and 11 men, median age 68.5 years. Analysis of initial symptoms, cardinal findings on first examination and pathological laboratory values pointed predominantly to a primary site in the abdomen. The following conclusions were drawn from this study, with all the disadvantages of retrospective analysis: in a majority of patients (14) the tumour mass could be localized in the upper abdomen. Primary sites include pancreas, biliary tract and gallbladder and possibly colon in the differential diagnosis. There is usually not a good response to chemotherapy. On the other hand, it is important to examine all organs for possible primary site of a carcinoma the metastases of which can be successfully treated by chemotherapy or hormones (mammary, ovarian, testicular, thyroid and prostate carcinoma). Taking into account a median survival time of 28 weeks and the fact that 73% of all technical investigations were normal, diagnostic measures should be as few as possible, restricted predominantly to clinical and biochemical ones, radiography of the thorax, abdominal ultrasound, digital pelvic examination, mammography, and serological and cytological tumour parameters.

Sonographic Methods of Evaluating Cervical Length: A Literature Review

Labor that begins between 20 and 37 weeks gestation is appropriately termed preterm labor. Some of the precipitating factors of preterm labor are changes in cervical status including dilatation and effacement. Until recently, a digital pelvic examination was considered the gold standard for evaluating cervical changes. Current research promotes the use of sonography for the prediction of preterm labor. It is essential for sonographers to become familiar with the various methods of cervical imaging including transabdominal, translabial, and transvaginal approaches. Each technique has its costs and benefits; however, a review of the current literature will show that the transvaginal method of cervical measurement is the most reliable.

Palm fronds and animal jaw in the vagina mimicking advanced cancer of the cervix

Herbal intravaginal medications are not uncommon in northern Nigeria, often used as aphrodisiacs or less commonly, to treat infective gynaecological conditions. Most of these medications are self-inserted. We report an unusual case of a 20-year-old patient with sickle cell disease with primary infertility who was referred from a general hospital with both clinical and radiologic evidence of advanced cancer of the cervix, for expert management. Speculum examination revealed copious dark frothy malodorous vaginal discharge with a huge necrotic irregular cervical mass extending to the upper two third of the vagina. Digital pelvic examination performed to clinically stage the tumor revealed the mass was made up of organized palm fronds and animal jaw, which were probably inserted for the patient 2 months ago as a therapy for primary infertility. The herbs were evacuated to reveal ulcer craters on the cervix, which bled on contact. Patient responded to antibiotic therapy and is being followed up in our clinic for the primary infertility.