Colposcopy

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS

The most common indications include the following:

  • Pap smear consistent with dysplasia or cancer
  • Pap smear with atypical glandular cells (always perform colposcopy)
  • Worrisome history despite Pap smear findings (e.g., postcoital bleeding)
  • An atypical Pap smear in which the patient tests positive for high-risk HPV
  • Suspicious visible lesion or palpable lesion of the cervix
  • Abnormal vaginal bleeding, especially if postcoital, regardless of Pap smear status
  • History of intrauterine diethylstilbestrol (DES) exposure
  • Evaluation or follow-up of previously treated or high-risk patients
EQUIPMENT
  • Colposcope: Variable fixed power or zoom lens (3× to 7× low power to 15× to 40× high power)
  • Biopsy forceps
  • Endocervical curette (Kevorkian curette, no basket)
  • Endocervical speculum† (Kogan, both narrow and wide types)
  • Ring forceps
  • Tenaculum† (rarely used)
  • Cervical hook† (rarely used)
  • Pap smear materials†
  • Vaginal speculums
  • Full-strength Lugol's iodine solution
  • Monsel's solution (ferric subsulfate), 1 mL
  • Acetic acid solution 3% to 5% (white vinegar; 4-6 oz or 120-180 mL)
  • Cotton- or rayon-tipped swabs (8-10)
  • Junior Scopettes/OB-GYN applicators (6-10)
  • 4 × 4 gauze
  • Urine or sputum cups for vinegar
  • Vaginal side wall retractor†
  • Underpads ("chuck pads") (17 × 24 inch)
  • Cotton balls (15-20)
  • Power-assisted patient examination table that can be raised or lowered (Minimum height should be no more than 24 inches from the floor, or older and disabled patients will have a difficult time getting onto it.)

Optional items include the following:

  • A pre-procedural dose of an oral NSAID
  • Aromatic ammonium capsules ("smelling salts") for vasovagal responses
  • A camera/video attachment for the colposcope
ANATOMY

Cervical Anatomy

  • The cervix is the distal portion of the uterus. Other segments of the uterus, moving proximally, are the isthmus, the corpus, and the fundus.
  • The endocervical canal is closed off from the main cavity of the uterus by a narrowing at the cervical isthmus.
  • The external opening on the cervix is the external os. The vaginal vault just outside the cervix ends at the vaginal fornix.
  • The area of the squamocolumnar junction (SCJ) marks the transition from the squamous epithelium of the exterior cervix to the columnar epithelium of the endocervical canal.

Endocervical Canal

  • The size of the endocervical canal is variable, but it usually is 2.5 to 3 cm long and up to 8 mm wide in the middle (usually the widest point).
  • In nulliparous women, the os is small and round. It is larger and irregular in women who have had a previous vaginal delivery.
  • The endocervical canal is lined with a layer of columnar epithelium that secretes mucus. The transformation to nonkeratinized stratified squamous epithelium (SCJ) occurs in the lower segment of the cervix.

Colposcopic Anatomy

  • The classic hallmark of cervical dysplasia includes the change that dysplastic epithelium undergoes after 3% to 5% acetic acid (vinegar) or Lugol's (concentrated iodine) solution is applied.
  • After acetic acid has been applied, dysplastic epithelium typically turns whiter than the surrounding normal epithelium (acetowhite epithelium). More advanced dysplasia typically appears denser, white, and thicker with more smooth and raised borders. The surface of advanced dysplasia often becomes more rough or thickened as the severity of dysplasia advances and satellite lesions are less common. A "yellowish" hue may be noted.
  • After Lugol's solution has been applied, an immediate blackening (staining) of normal epithelium occurs (iodine uptake is high in normal cells that are rich in cytologic glycogen); abnormal dysplastic tissue, which includes cells that contain much less intracellular glycogen, is not stained by iodine (Lugol's negative epithelium) and remains white or faint yellow.
  • Changes in the vasculature pattern also correlate with cervical dysplasia. These abnormal patterns, which often occur within an acetowhite or leukoplakia patch, include punctation, mosaicism, and frankly abnormal vessel variations. The more coarse the punctation or mosaicism, the more severe is the dysplasia. Frankly abnormal vessel patterns imply severe dysplasia or invasive carcinoma.
  • Squamous metaplasia, a normal finding, may appear slightly acetowhite and may take up Lugol's iodine incompletely; therefore, this tissue can cause some degree of confusion for the colposcopist. Squamous metaplasia is physiologically normal tissue in which the columnar epithelium is being transformed into mature squamous epithelium. This occurs in the TZ—the same site where dysplasia generally occurs. Squamous metaplasia is especially prominent with certain conditions such as active cervicitis, and when healing and reparative activities occur such as after treatment. Questionable areas always warrant biopsy. If squamous metaplasia without dysplasia is reported on biopsy when the Pap smear was abnormal, the prudent colposcopist must look elsewhere to explain the finding of dysplasia on the Pap smear (please refer to http://www.asccp.org/consensus/cytological.shtml for more information on the ASCCP guidelines). A report of squamous metaplasia among other biopsies that reveal dysplasia reflects the difficulty encountered by the colposcopist in evaluating this normal variant of acetowhite change.
  • The other normal area that commonly turns slightly white with acetic acid is the area of the endocervical (columnar) cells, which typically are located within the cervical canal and extend a variable distance onto the exocervix. Endocervical tissue generally can be differentiated from abnormal cervical areas by colposcopic examination because of its grape-like appearance on high-power magnification. Biopsy still is warranted if any confusion arises about whether or not a given finding is abnormal.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Agree on a time to discuss and interpret biopsy findings by phone or follow-up visit.
  • Explain that mild vaginal discharge may occur and may last approximately 24 hours.
  • Advise the patient that she may have spotting for at least 48 hours.
  • Instruct the patient to report passage of clots, onset of fresh profuse bleeding, foul vaginal odor, fever, or pelvic pain.
  • Encourage the patient to continue contraception.
  • Some women may have vaginitis, and therapy aimed at these pathogens may be helpful.
  • Emphasize the importance of returning for definitive therapy.
  • Reemphasize lifestyle issues associated with risk for cervical dysplasia.
COMPLICATIONS
  • Most bleeding is minimal and is controlled with Monsel's solution.
  • A foul cervical discharge, fever, or pelvic pain may indicate a post-procedure infection.
  • Despite correct technique, the disease may be missed.
  • Vaginal discharge often looks like coffee grounds.
  • Cervical biopsy sampling typically causes brief pain and discomfort.
  • Rarely, vasovagal reactions occur with the procedure.
RESULT ANALYSIS

Colposcopic Findings

  • Normal Colposcopic Findings
    • Original squamous epithelium
    • Columnar epithelium
    • Transformation zone (TZ)
    • Squamous metaplasia
    • Squamocolumnar junction (SCJ)
  • Abnormal Colposcopic Findings
    • Atypical TZ
    • Acetowhite epithelium
    • Punctation
    • Mosaicism
    • Leukoplakia (hyperkeratosis)
    • Abnormal blood vessels
    • Suspicion of invasive cancer
  • Unsatisfactory Colposcopy
    • A colposcopy is unsatisfactory if the entire SCJ or the limits of all lesions cannot be visualized completely. Proper examination can be hampered if an active inflammatory process is present, if the patient is not estrogen primed, or if heavy menses is present.
  • Other Colposcopic Findings
    • Vaginocervicitis
    • Traumatic erosion
    • Atrophic epithelium
    • Endocervical polyps
    • Changes from diethylstilbestrol (DES)
    • Abnormal pigmentation
    • Nabothian cysts
    • Posttraumatic clefts, deformities from birth or treatment
    • Vaginal, vulvar, perineal, perianal lesions
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