Introduction to Colposcopy

Transcription

1 Introduction to Colposcopy Papanicolaou smear (Pap smear) screening test Colposcopy diagnostic test

2 Introduction to Colposcopy Acetic acid and Lugol s iodine applied Cervix examined under magnification Abnormal areas identified Directed biopsies performed Leads to a tissue diagnosis

3 Indications ASCUS Pap with high risk HPV or worse Pap smear with ASC-favor HG Atypical Glandular Cells Pap smear with repeated inflammation Abnormal-appearing cervix History of intrauterine DES

4 Normal Colposcopic Findings Squamocolumnar Junction (SCJ) Visible line Demarcates columnar and squamous epithelium Anatomical feature

5 Normal Colposcopic Findings Transformation Zone (Tz) Geographic area between the original squamous epithelium and SCJ Contains gland openings & Nabothian cysts Contains islands of columnar surrounded by metaplastic squamous epithelium

6 Normal Colposcopic Findings Transformation Zone Prepuberty SCJ stable Original SCJ

7 Abnormal Colposcopic Findings Leukoplakia Elevated, white plaque seen prior to the application of acetic acid

8 Abnormal Colposcopic Findings Abnormal blood vessels Irregular vessels Abrupt courses and patterns Commas, hairpins, corkscrews No pattern

9 Colposcopy Technique Obtain informed consent and answer patient's questions Make sure you know the pregnancy status of your patient A bimanual exam should have been done with annual exam If not, perform it now

10 Colposcopy Technique Examine the cervix Do cultures if necessary Gently blot (not wipe) excess mucous using saline Look for leukoplakia

11 Colposcopy Technique Apply 5% acetic acid with a cotton ball or rectal swab Repeat application every five minutes

12 Colposcopy Technique Apply 5% acetic acid

13 Colposcopy Technique Green Filter Helps highlight vessels

14 Unsatisfactory Colposcopy Colposcopy assumes the worst parts are biopsied Requires that the Tz, including all the SCJ, and borders of all lesions be seen Inadequate colposcopy requires more work-up.

15 Unsatisfactory Colposcopy Requires that the Tz, including all the SCJ, and borders of all lesions be seen

16 Grading Lesions Reid Colposcopic Index Formal system of assessing severity of cervical dysplasia Point system to grade the lesion margins, color, blood vessel pattern, and strong iodine staining More objective - not universally used Reid R. Am J Obstet Gynecol 1985; 153:611-8.

17 Colposcopy Technique Sharp geographic borders, thickness, or roughness are more severe Vessel atypia = more severe dysplasia Reid R. Clin Obstet Gynecol 1989; 32:157-79

18 Colposcopy Technique Lugol's solution (Schiller's test) Need not be used in all cases Helpful on the vagina and proximal vulva Examine for glycogendeficient areas

19 Lugol s Iodine

20 ECC and Biopsy Cervical biopsy Biopsy posteriorly first to avoid blood dripping Biopsy approximately 3 mm deep include all areas with vessel atypia not necessary to include nl margins If bleeding, apply a Q-tip and proceed to the next biopsy

21 ECC and Biopsy The fixed jaw of the forcep is placed on the most distal part of the site

22 ECC and Biopsy Center jaws over the area to be biopsied

23 ECC Never do an ECC on a pregnant patient!

24 Colposcopy Technique - ECC Scrape the canal, 360 degrees, twice Sample appears as coagulum of mucus, blood, and tissue Use ring forceps or cytobrush to gently retrieve the sample

25 ECC and Biopsy

26 ECC and Biopsy Monsel's solution Do not apply until biopsies are completed Apply pressure first and Monsel's if needed Ideally, Monsel's should be as thick as toothpaste

27 ECC and Biopsy

28 Colposcopy Technique Gently remove the speculum View the vaginal wall collapse around the speculum Examine the vulva for lesions Have the patient rest supine, then sit up slowly

29 Colposcopy Technique Post-procedure instructions No douching, intercourse, or tampons for two weeks Return for foul vaginal odor or discharge, pelvic pain, or fever Tylenol, Ibuprofen, or Aleve may be used for cramps

30 Documentation Note the shape, position, and findings of all lesions in order to draw a picture of the lesions and biopsy sites

31 Follow-Up Follow-up is usually in 1 to 3 weeks Discuss pathology results and plan treatment