The Role of Culdocentesis in Evaluating Pelvic Pain in Women

The role of culdocentesis in evaluating pelvic pain in women

MICHAEL L. MANSI, D.O. Philadelphia, Pennsylvania

has been found to be a high degree of correlation This paper analyzes the results of 126 between cultures of organisms obtained via culdo- culdocenteses performed using either centesis and those obtained at laparoscopy or lapa- one of two culdocentesis techniques. rotomy.6 For these reasons, culdocentesis still has All of the women in this study a place in the clinical evaluation of the female presented to the emergency with pelvic pain. department with a chief complaint of The purpose of this paper is to analyze the re- pelvic pain. All had verification of sults of 126 culdocenteses performed using either pelvic findings via laparoscopy one of the two techniques explained below. All of and/or laparotomy. In this study the patients had verification of pelvic findings via group, the overall accuracy rate of laparoscopy and/or laparotomy. With this follow- culdocentesis was 94.5 percent. There up information available for comparison, the reli- were no complications, side effects, ability of culdocentesis when evaluating the fe- or deaths. Even with the advanced male patient with pelvic pain is demonstrated. medical technology of the 1980s, culdocentesis remains a valuable aid Materials and methods in the evaluation of the female patient All of the 126 patients in this study were evaluat- with pelvic pain. ed in the emergency departments of the authors training hospitals during the 5-year period from July 1, 1976, to June 30, 1981. The patients ranged in age from 15 to 43 years of age. They came from varied socioeconomic backgrounds. All of them had a chief complaint of pelvic pain at the Culdocentesis, the needle aspiration of fluid from time of their evaluation. Many of the women had the pouch of Douglas (posterior cul-de-sac), has associated complaints (Table 1). (Many had more long been part of the armamentarium of the obste- than one additional complaint.) trician/gynecologist. 1-5 Even with the advanced The patients in this study were subjected to ei- medical technology of the 1980s, culdocentesis re- ther one of two techniques of culdocentesis. For mains a valuable aid in the evaluation of the fe- purposes of discussion, the techniques are desig- male patient with pelvic pain. nated A and B, respectively. A discussion of each Culdocentesis can help the clinician differenti- follows. ate between the inflammatory and hemorrhagic causes of pelvic pain. For example, in the patient Technique A with a ruptured tubal ectopic pregnancy or a rup- Figure 1 shows the needle utilized in Technique A tured ovarian cyst, valuable time can be saved if a culdocentesis and the actual technique employed bloody aspirate is obtained on culdocentesis. With is demonstrated in Figure 2. Technique A can be this finding, the clinician could immediately pro- considered the traditional method of culdocentesis ceed to surgical management of the problem. Also, described in most obstetrics and gynecology blood banking time could be saved in preparation texts.7-16 A 31/2-inch, 18-gauge, Monoject R spinal for surgery. On the other hand, in patients with needle is used. such inflammatory pelvic diseases as salpingitis or The procedure is first explained to the patient tubo-ovarian abscess, cul-de-sac aspiration will in-depth. Then, a permit for the procedure is also aid the physician in instituting therapy. Aspi- signed. The bladder is emptied, and the patient is rates can be sent for Grams stain, and antimicro- placed in the dorsal lithotomy position. A bivalve bial therapy can be initiated based on these find- speculum is inserted in the vagina and the posteri- ings, while awaiting final culture results.6 In the or lip of the cervix is grasped with a tenaculum. patient with pelvic inflammatory disease, there The cervix is elevated and an antiseptic solution of

The role of culdocentesis in evaluating pelvic pain in women 576/71 TABLE 1. FREQUENCY OF THE PATIENTS ASSOCIATED COM- then introduced into the cul-de-sac using one quick PLAINTS. motion. Aspiration is performed using the 20 cc. sy- Complaint Number of patients ringe. If blood is obtained, it is placed in a glass Pelvic pain (left lower quadrant, 126 test tube and observed for clot formation for 10 right lower quadrant) minutes. If purulent material is aspirated, it is im- Vaginal bleeding mediately sent for Grams stain, and aerobic and (not following amenorrhea) 60 anaerobic cultures. If a nonbloody, nonpurulent Vaginal discharge 42 Fever (100.4) 36 material is aspirated, it is sent to the pathologist Vaginal bleeding for cell-block analysis. Should no aspirate be ob- (following amenorrhea) 28 tained on the initial attempt, the procedure is re- Shoulder pain 20 Nausea/vomiting/anorexia 19 peated once and then abandoned. Thirty-six culdo- Amenorrhea 18 centeses were performed in this fashion. Syncope 11 Right upper quadrant pain 3 Rectal pain 2 Technique B Technique B is actually an outgrowth of the short- comings of Technique A. On multiple occasions when employing Technique A, many patients be- come apprehensive of the procedure after viewing the size of the spinal needle. One can readily un- derstand the patients fear when presented with this instrument. Also, one must exercise extreme caution when performing this technique for fear of bowel, uterus, or blood vessel injury. The likeli- hood of injury increases if the patient should make a sudden movement during the procedure. These two factors, along with the authors distrust of the techniques accuracy, led to the modification of Technique A and the development and employ- ment of Technique B. Figure 3 illustrates the equipment utilized in Technique B culdocentesis. Figure 4 demonstrates the actual technique used. In Technique B, the patient is prepared in a fashion similar to Technique A. However, instead of a 31/2-inch, 18-gauge, spinal Fig. 1. Needle used in Technique A culdocentesis. needle, a 19-gauge, butterfly-type, E-Z Set R needle is employed. This butterfly needle is 7/8 inch in length and the inside bore is 19 gauge. The butterfly needle is held in a ring-tip forcep and the tubing channel is attached to a 10 cc. Luer-LokR syringe. The needle is introduced into the cul-de-sac via the midline of the posterior vaginal fornix using one quick motion. Negative pressure is exerted on the syringe plunger while the needle is slowly withdrawn. Aspirated material can easily be viewed first in the transparent tubing channel and then in the syringe itself. Aspirated material is treated identically to that obtained via Technique A. Again, if no aspirate is obtained, the procedure is repeated once and then abandoned. A total of ninety culdocenteses were performed in this fashion. The author found this technique to be very Fig. 2. The method of Technique A culdocentesis. simple to perform; it was also acceptable to the patient.

povidone-iodine is applied to the vaginal vault Results with attention to the posterior vaginal fornix. The All of the culdocenteses were performed by the au- needle, attached to a 20 cc. Luer-LokR syringe, is thor without incident. There were no complica-

577/72 Aprd 191111Ahnousl GEA0A/voL Ohm tions as proven by laparoscopy and/or laparotomy had ruptured ovarian cysts without hemoperitone- confirmation. A positive culdocentesis was record- um. Six patients had tubo-ovarian abscesses. Fif- ed if either blood, purulent material, or such cystic material as follicular or endometriotic fluid was aspirated. If no aspirate was obtained, a negative culdocentesis was recorded. Table 2 illustrates the results of 126 culdocenteses (taps). There were thirty-four negative taps and there were ninety- two positive taps. Of the ninety-two positive findings, fifty-three were bloody, twenty-six were purulent, and thirteen contained cystic fluid. The data can now be analyzed according to the culdocentesis technique used (Tables 3 and 4). When Technique A was utilized, there were thirteen negative taps and twenty-three positive taps. The positive culdocenteses were distributed as follows: eleven, bloody, seven purulent; and five, cys- 111.11.111111111§1.11 tic fluid. Utilizing Technique B, there were twen- Fig. 3. ty-one negative taps and sixty-nine positive taps. Equipment employed in Technique B culdocentesis. The positive culdocenteses were distributed as follows: forty-two, bloody; nineteen, purulent; and eight, cystic fluid. To make such a study meaningful, the detailed pathologic findings must be available in each case. 1 k i° These operative findings (at laparoscopy and/or ,----,- .4 laparotomy) for all of the patients are detailed in \■;, \‘k.) Table 5. The culdocentesis findings are also con- 0.--,,..-...... „,„ trasted with the operative findings in each cate- gory. Sixteen patients had normal pelvic anatomy at surgery; no pathologic condition could be identi- fied. Thirty-nine patients had either ruptured or leaking tubal ectopic pregnancies. Sixteen women had ruptured ovarian cysts with hemoperitoneum while another fourteen had ruptured ovarian cysts without hemoperitoneum, but with cystic fluid. Fig. 4. The method of Technique B culdocentesis.

Ten patients had tubo-ovarian abscesses. Twenty TABLE 2. CULDOCENTESIS RESULTS IN 126 PATIENTS. patients had salpingitis with free pelvic pus while Number of patients Percent eleven patients had salpingitis without free pelvic Negative culdocentesis 34 26.9 pus. Positive culdocentesis 92 73.1 Once again, the above data can be analyzed ac- Bloody aspirate 53 57.7 cording to the technique of culdocentesis used (Ta- Purulent aspirate 26 28.2 Cystic fluid aspirate 13 14.1 bles 6 and 7). The culdocentesis findings are com- pared against the actual operative findings. When TABLE 3. RESULTS OF TECHNIQUE A CULDOCENTESIS IN THIRTY- Technique A was employed, six patients were not- SIX PATIENTS. ed to have normal pelvic anatomy. There were Number of patients Percent nine patients with ruptured or leaking tubal ectop- Negative culdocentesis 13 36.1 ic pregnancies. Four patients had ruptured ovar- Positive culdocentesis 23 63.9 Bloody aspirate 11 47.8 ian cysts with hemoperitoneum while six had rup- Purulent aspirate 7 30.4 tured ovarian cysts without hemoperitoneum. Cystic fluid aspirate 5 21.8 Four patients had tubo-ovarian abscesses. Five patients had salpingitis with free pelvic pus and two TABLE 4. RESULTS OF TECHNIQUE B CULDOCENTESIS IN NINETY PATIENTS. had salpingitis without free pelvic pus. When Technique B was utilized ten patients were ob- Number of patients Percent served to have normal pelvic anatomy. There were Negative culdocentesis 21 23.3 Positive culdocentesis 69 76.7 thirty patients with ruptured or leaking tubal ec- Bloody aspirate 42 60.8 topic pregnancies. Twelve women had ruptured Purulent aspirate 19 27.5 ovarian cysts with hemoperitoneum while eight Cystic fluid aspirate 8 11.7

The role of culdocenteds in evaluating pelvic pain in women 578/73 TABLE 6. OPERATIVE FINDINGS IN THE 126 WOMEN STUDIED. Operative culdocentesis findings Number of patients Percentage Positive tap Percentage Negative tap Percentage Normal pelvis 16 12.7 0 0.0 16 100 Ruptured or leaking tubal 39 31.0 38 97.4 1 2.6 ectopic pregnancy Ruptured ovarian cyst with 16 12.7 15 93.7 1 6.3 hemoperitoneum Ruptured ovarian cyst without 14 11.2 13 92.8 1 7.2 hemoperitoneum (follicular, endometrioma) Tubo-ovarian abscess 10 7.9 8 80.0 2 20.0 Salpingitis with free 20 15.8 18 90.0 2 10.0 pelvic pus Salpingitis without free 11 8.7 0 0.0 11 100 pelvic pus

TABLE 6. TECHNIQUE A CULDOCENTESIS FINDINGS. Operative and culdocentesis findings Number of patients Percentage Positive tap Percentage Negative tap Percentage Normal pelvis 6 16.7 0 0 6 100 Ruptured or leaking tubal 9 25 8 88.8 1 11.2 ectopic pregnancy Ruptured ovarian cyst with 4 11.1 3 75 1 25 hemoperitoneum Ruptured ovarian cyst without 6 16.7 5 83.3 1 16.7 hemoperitoneum (follicular, endometrioma) Tubo-ovarian abscess 4 11.1 3 75 1 25 Salpingitis with free 5 13.9 4 80 1 20 pelvic pus Salpingitis without free 2 5.5 0 0 2 100 pelvic pus

TABLE 7. TECHNIQUE B CULDOCENTESIS FINDINGS. Operative and culdocentesis findings Number of patients Percentage Positive tap Percentage Negative tap Percentage Normal pelvis 10 11.1 0 0 10 100 Ruptured or leaking tubal 30 33.3 30 100 0 0 ectopic pregnancy Ruptured ovarian cyst with 12 13.3 12 100 0 0 hemoperitoneum Ruptured ovarian cyst without 8 8.9 8 100 0 0 hemoperitoneum (follicular, endometrioma) Tubo-ovarian abscess 6 6.7 5 83.3 1 16.7 Salpingitis with free 15 16.7 14 93.3 1 6.7 pelvic pus Salpingitis without free 9 10 0 0 9 100 pelvic pus

TABLE 8. OPERATIVE FINDINGS (ASPIRATE) VERSUS CULDOCENTESIS FINDINGS. Operative findings Number of patients Positive taps Percentage Negative taps Percentage Blood 55 53 96.3 2 3.7 Pus 30 26 86.6 4 13.4 Other 14 13 92.8 1 7.2

teen patients had salpingitis with free pelvic pus centesis findings. There were fourteen operative while nine had salpingitis without free pelvic pus. findings of cystic fluid in the pelvis and there were Table 8 compares the operative findings, ex- thirteen nonbloody, nonpurulent, culdocentesis as- pressed as the type of aspirate, with the culdocen- pirates. tesis findings. There were fifty-five operative find- Having reviewed all of the culdocentesis findings of blood in the pelvis and fifty-three bloody ings and operative findings for the 126 patients, culdocentesis aspirates. There were thirty findings the accuracy of culdocentesis in this study popula- of pus in the pelvis and twenty-six purulent cu1do- tion can be correlated. There were no false-positive

579P74 Apri11984/Jounuil of AOA/vol. 83/no. 8 results. A false-positive culdocentesis can be de- gonococcal infection with destruction of the endo- fined as obtaining an aspirate on culdocentesis salpinx and alteration of the ovum transport, when none was present at the time of surgery. seems to be reason itself. The widespread use of However, there were seven false-negative culdo- the intrauterine contraceptive device may also be centeses. A false-negative culdocentesis can be de- a contributing factor and the rise in pelvic and re- fined as obtaining no aspirate on culdocentesis constructive tubal surgery may be a predisposing when one was present at the time of surgical inter- factor as well. vention. These false negatives represent a rate of These problems demand a rapid and accurate di- 5.5 percent for the entire study. The accuracy of agnosis. Ultrasonography has greatly helped the culdocentesis in this study was 94.5 percent, which clinician in identifying pelvic disease. However, is certainly very acceptable and similar to that of ultrasonography is still not available on a world- other studies.17.18 wide basis. It is certainly not available in all insti- When Technique A was employed, five false- tutions on a 24 hour per day basis. In rural areas, a negative taps out of thirty-six patients were ob- patient may have to be referred to a large urban tained (13.8 percent). The following were missed center for even routine ultrasonography. The aver- with Technique A: a ruptured tubal ectopic preg- age B-scan of the pelvis takes approximately 30 nancy, a ruptured ovarian cyst with hemoperito- minutes to perform. So, as in Cushings time, cul- neum, a ruptured ovarian cyst without hemoperi- docentesis remains a safe, rapid, and valuable ad- toneum, a tubo-ovarian abscess and salpingitis junct in the assessment of pelvic pain and disease. with free abdominal pus. When Technique B was It can be performed in the outpatient or emergency employed, two false-negative taps out of ninety departments without delay. No elaborate equip- were obtained (2.2 percent). A tubo-ovarian ab- ment is required. scess and salpingitis with free pelvic pus were In this study, an overall accuracy rate of 94.5 missed when Technique B was utilized. Technique percent was achieved. When Technique B was em- B was clearly the more accurate method of culdo- ployed, the accuracy rate improved to 97.8 percent. centesis. No patient with a hemorrhagic cause for Equally important, the procedure was readily ac- pelvic pain was missed using Technique B, while cepted by the patient. No complications were in- two were missed with Technique A. The two false- curred. No patient with hemoperitoneum was negative taps with Technique B occurred in pa- missed using Technique B; the two false-negative tients with inflammatory conditions. The overall results occurred in the inflammatory disease accuracy rate of Technique B was 97.8 percent. groups. This may have been caused by the extreme More importantly, culdocentesis with the 19- viscosity or tenacity of the purulent exudate, and gauge butterfly needle is easier for the clinician to thus its inability to be aspirated through a 19- perform. It is also more readily accepted by the pa- gauge needle. tient. Culdocentesis can aid the clinician in diagnos- ing ruptured or leaking tubal ectopic pregnancy, Discussion ruptured ovarian cyst, tubo-ovarian abscess, and Culdocentesis has long been employed as a diag- salpingitis with free pelvic puss. The procedure nostic aid in pelvic inflammatory disease. Almost could also be used in evaluating the female patient 100 years ago, Cushing wrote, "I would urge also with hemoperitoneum secondary to blunt abdomi- the free use of the aspirating needle in all cases of nal trauma,4.2° and intraabdominal hemorrhage obscure pelvic disease in which the local or consti- from one of the following causes: ruptured duode- tutional symptoms would indicate the presence of nal or gastric ulcer, ruptured spleen, ruptured liv- pus." Conversely, the gynecologic literature er, ruptured splenic artery aneurysm, and rup- abounds with documentation of the value of culdo- tured aortic aneurysm.7 centesis in the diagnosis of tubal ectopic pregnan- Culdocentesis can facilitate the institution of cy.2,3,5,17,18 antimicrobial therapy.6,21 And, when hemoperi- Unfortunately, infections and hemorrhagic pel- toneum is diagnosed, the clinician can promptly vic disease will continue to pose an ever-increasing notify blood banking facilities of the possible need challenge to todays clinician. Indeed, the inci- for transfusion. When the diagnosis of ruptured dence of ectopic pregnancy continues to rise. In one tubal ectopic pregnancy is strongly suspected and large series, one ectopic pregnancy was found per the culdocentesis is positive for nonclotting, bloody seventy-eight intrauterine pregnancies." The rea- aspirate, the clinician may elect to bypass laparos- son for this trend appears to be multifactorial. copy in favor of immediate laparotomy. This will Changing sexual mores may be a contributing fac- conserve precious time as well as drastically re- tor. The increase in pelvic infection, specifically duce the operative and anesthetic time. In this sit-

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