Colposcopy

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Chapter 238 Colposcopy

DESCRIPTION

Colposcopy is a diagnostic technique that allows the clinician to identify normal landmarks, find changes suggestive of underlying abnormality, and select sites for biopsy that will yield the greatest information.

Colposcopy is based on a simple stereoscopic operating microscope with magnifications of from 4 to 40 times. Although most often used to examine the uterine cervix, colposcopy may be used to evaluate the vagina, vulva, and other structures.

INDICATIONS

Abnormal cervical cytology (atypia, cancer, dysplasia, koilocytosis), cervical lesions (palpable or visible), condyloma (current or past; relative indication), human immunodeficiency virus (HIV) infection, intrauterine diethylstilbestrol (DES) exposure, surveillance or follow-up.

CONTRAINDICATIONS

Colposcopy is not recommended for adolescents or pregnant patients with Pap test abnormalities of low-grade squamous intraepithelial lesions (LSIL). Endocervical curettage is contraindicated during pregnancy.

REQUIRED EQUIPMENT

• Colposcope with light source

• Endocervical speculum

• Biopsy forceps (e.g., Tischler, Kevorkian)

• Endocervical curette

• Large cotton-tipped swabs, cotton balls, or small gauze sponges

• Examination gloves

• Vaginal speculum

• Tenaculum (optional)

• Acetic acid (3% to 5%) (white vinegar)

• Monsel solution (ferric subsulfate)

• Lugol (5%) solution (supersaturated iodine) (optional)

• Sputum or urine cups (to hold solutions)

• Sterile gloves (optional) (Any instrument that will enter the endocervical canal or will be used for biopsy should be sterilized before use. The use of sterile gloves is not required as long as the portions of instruments that will come in contact with the patient remain sterile.)

• Video, photographic, or digital capture equipment may be attached to the hysteroscope as desired (optional)

TECHNIQUE

The patient is placed in the dorsal lithotomy position. (If a bimanual examination is performed, the amount of lubricant used should be limited because this lubricant, and glove powder, can adversely affect cytologic studies.) By use of the largest warmed but unlubricated speculum the patient can comfortably accommodate, the cervix should be brought into full view. Following gross inspection for lesions, excessive secretions may be gently blotted away, cultures obtained, or a repeat Papanicolaou (Pap) smear taken.

The colposcope should be positioned to provide an unobstructed view of the cervix and maintained in a position and height that is comfortable for both the patient and the examiner. Acetic acid (3% to 5%) should be liberally applied to the cervix with large cotton-tipped applicators, cotton balls, or small gauze sponges. Acetic acid causes the columnar epithelial cells to swell and opacifies metaplastic and dysplastic cells. The changes brought on by the application of acetic acid are only temporary, requiring periodic reapplication at roughly 5-minute intervals.

Inspection of the cervix begins using the lowest magnification, with additional magnification added later, if needed. The transformation zone should be identified and inspected in its entirety. If necessary, the cervix may be manipulated using an acetic acid–soaked applicator stick, a cervical hook (similar to a skin hook retractor), or an endocervical speculum.

For a colposcopy to be considered “adequate” the entire transformation zone must be visualized. The full extent of any lesion present must also be visible for the study to be considered adequate. If the colposcopy is “inadequate,” diagnostic conization will be required. Any areas of white change, vascular abnormality, or mosaicism should be inspected under greater magnification. Vascular patterns may be enhanced by the interposition of a green filter in the colposcope’s light path, making the vessels appear black against the pale background of the epithelium.

Any area of abnormality identified should be biopsied. (Although rarely necessary, abnormal areas may be stained with Lugol solution to aid this identification.) When multiple abnormalities are present, biopsies of the most severe areas take precedence. Whenever possible, the biopsy should include the edge or border of the lesion. Biopsies should be placed in a buffered formalin solution for transport to the pathology laboratory.

Curettage of the endocervical canal (ECC) should generally be included to exclude the possibility of endocervical lesions above the limits of visibility. The ECC is especially helpful as a first stage in the evaluation of atypical glandular cells.

If bleeding from a biopsy site persists or is heavy, Monsel solution may be applied. Monsel solution should be applied only after all specimens have been obtained.

For colposcopy of the vulva, a weaker concentration of acetic acid will result in less burning and discomfort. Because of the relatively thicker epithelium of the vulva, the acetic acid must be left in contact with the tissues for a longer period (even if the stronger solution is chosen). Soaking a gauze sponge and allowing it to remain in contact with the skin for several minutes most easily accomplish this.

COMPLICATIONS

Transient bleeding from biopsy sites. Infection at the biopsy site or endometrium is rare. (Colposcopic examinations fail to visualize the squamocolumnar junction or the limits of any lesions present [inadequate studies] in roughly 15% to 20% of premenopausal women.)

FOLLOW-UP

Follow-up is dictated by the indication for the procedure and any lesions found. A review of the histology reports on any material removed may also alter the follow-up indicated. No specific procedure-related follow-up is needed, although if extensive biopsies are taken, pelvic rest (no tampons, douches, or sexual intercourse) for a period of time may be prudent. The patient should be advised to expect an increased vaginal discharge if biopsies were taken and Monsel solution was used. An abnormal discharge or vaginal bleeding should prompt a re-evaluation.

CPT CODE(S)

57452 Colposcopy (Vaginoscopy); (separate procedure)

57454 Colposcopy with biopsy(s) of the cervix and/or endocervical curettage

57460 Colposcopy with loop electrode excision procedure of the cervix

57500 Biopsy of cervix only, single or multiple

57505 Endocervical curettage (not done as part of a dilatation and curettage)

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