Culdocentesis

By: Dr Mehrabuddin
FM Resident
Afshar Hospital 22/09/10
 Objectives
• Definition
• INDICATIONS 
• CONTRAINDICATIONS 
• PREPARATION
• MATERIALS
• PROCEDURE
• INTERPRETATION OF FINDINGS 
• COMPLICATIONS
• SUMMARY AND RECOMMENDATIONS
 Definition
• Culdocentesis is a procedure in which
peritoneal fluid is aspirated transvaginally
from the posterior cul-de-sac (pouch of
Douglas)
 Indication
• In 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
• Ruptured ovarian cyst
• Pelvic inflammatory disease
• Ruptured ectopic pregnancy
 CONTRAINDICATIONS
• Cysts, masses, or other structures in posterior
cul-de-sac that might contaminate the
peritoneal cavity if perforated or that could
impede access to free fluid in the posterior
cul-de-sac (therefore bimanual examination
should be done)
• Fixed retroverted uterus
• Bleeding diathesis
 PREPARATION

• Review the patient's history ( Bleeding Dis)

•   Perform a pelvic (bimanual) examination
(possible pathology)
• Obtain written informed consent
• walk or sit upright for 10 to 15 minutes
• Organize instruments for the procedure
• Explain each step to pt and inquire about allergy
 MATERIALS

• Speculum
• Gloves
•  Single toothed tenaculum
•  18-gauge needle attached to a 20 mL syringe
containing 5 mL of normal saline
•  Sterile swabs or sponges

 
 MATERIALS
• Long handled ringed forceps
 • A suitable antiseptic, such as povidone iodine
 • Specimen containers
 • A local anesthetic (eg, 2 percent lidocaine gel)
 • Monsel's solution (ferric subsulfate) to control
bleeding
 PROCEDURE
• Anesthesia (Paracervical block or no
anesthesia are other options)
• Steps
1. Place patient in the dorsal lithotomy position
with the head tilt 60
2. Insert speculum to visualize cervix
3. Cleanse vagina and cervix with antiseptic
(povidone iodine)
 4- Apply 2 percent lidocaine gel to the posterior
vagina and posterior cervical lip (optional)
5- Grasp the posterior lip of the cervix with the
tenaculum and lift the cervix slightly to
expose the posterior fornix
6- Insert an 18-gauge needle attached to a 20
mL syringe containing 5 mL of normal saline
7- Inject 5 mL of normal saline (or air)
8- Aspirate peritoneal fluid, and then remove
the needle slowly
 INTERPRETATION OF FINDINGS
• A small amount of clear fluid is normal.
Copious peritoneal fluid suggests a ruptured
fluid filled cyst or ascites
• No fluid in the posterior cul-de-sac can also be
a normal finding. However, a dry tap is
considered unsatisfactory and suggests that
the needle tip is obstructed by tissue due to
poor positioning, adhesions, or other
pathology.
• Nonclotting blood indicates active intraperitoneal
bleeding. Determine the hematocrit: A hematocrit over
15 percent is most consistent with hemorrhage from a
ruptured ectopic pregnancy or actively bleeding
ruptured corpus luteum while a hematocrit less than 8
percent is more consistent with blood tinged fluid from
a ruptured ovarian cyst or pelvic inflammation.
• Clotting blood suggests blood from a vein or artery
may have been aspirated.
• The presence of pus indicates an infectious process,
possibly as abscess.
 COMPLICATIONS
•  Serious complications are rare
• There is risk of puncturing the anterior
division of the internal iliac vessels or the
obturator or pudendal nerve. Inadvertent
bowel perforation generally does not lead to
morbidity.
 SUMMARY AND RECOMMENDATIONS
• peritoneal fluid is aspirated transvaginally from
the posterior cul-de-sac
• A bimanual exam is performed before the
procedure
• An 18-gauge needle attached to a 20 mL syringe
containing 5 mL of normal saline
• Detection of a small amount of clear fluid is
normal. Copious clear fluid suggests a ruptured
fluid filled cyst or ascites
Thank you