Prof. Aboubakr Elnashar Benha University Hospital. EGYPT ABOUBAKR ELNASHAR

Update of colposcopy of genital HPV Meisels et al (1982):

Florid,

spiked,

flat,

condylomatous vaginitis.

Flat condyloma & mild dysplasia represent the same biologic phenomenon, namely, productive HPV infection (Reid,1993).

ABOUBAKR ELNASHAR

The expression of viral activity may be clinical or

subclinical when it is recognizable only on colposcopy.

Exophytic & flat condylomata are not homologous diseases.

Exophytic is usually caused by cutaneotropic viruses (6,11).

Flat are more likely to contain medium(31,33) or

high risk(16,18) HPV types.

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Micropapillary condyloma should not be confused with micropapillomatous labialis.

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Colposcopy of the vulva

*Steps:

1.Examination after smearing with a water soluble lubricant.

2.Prolonged acetic acid test

3.Toludine blue test: little clinical value.

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* The junction between the glycogen bearing vaginal epithelium & keratin producing vulval epithelium: high risk for intraepithelial neoplasia.

*Abnormalities:

diffuse acetowhite,

localized acetowhite,

leukoplakia,

micropapillae,

papules.

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Colposcopy of the vagina

Colposcopy of the vagina is complicated by four

problems:

preinvasive disease of the vagina is often multifocal;

the area to be examined is large &

most of it is difficult to view at right angles;

many of these patients have already had a

hysterectomy so not all of the area involved may be

visible.

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Because the treatment of vaginal intraepithelial

neoplasia (VAIN) is so difficult, it is more important

to differentiate viral disease from premalignant

lesions.

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In general:

1.The colposcopic features of VAIN are similar to

those seen in CIN.

2.The colposcope must be moved from side to side

to examine the opposite wall, & it sometimes helps

to withdraw & rotate the speculum slightly while

looking through the blades from the side.

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3.The anterior & posterior walls of the lower half of

the vagina can be inspected while slowly

withdrawing the speculum.

4.Application of lugol’s iodine is essential after

inspection with acetic acid to reduce the risk of

overlooking an area of abnormality.12-14

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Update on colposcopy in pregnancy

Difficult. & reserved for the most experienced colposcopist.

Reassurance of the patient.

ECC is contrindicated & one directed biopsy.

Large speculum is usually needed

Sponge forceps to remove the mucous & acetic acid as a mucolytic

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Unsatisfactory colposcopy: repeat after 8 w

The aim is to exclude cancer

CIN: follow up &

definitive treatment 1-2 mo postpartum.

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Pitfalls in practice of colposcopy

A. In the technique

1. Failure to use a diagnostic protocol

2. Deviation from a diagnostic protocol.

3. Failure to visualize TZ.

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B. In diagnosis

1. Misinterpretation of exaggerated patterns of pregnancy, previously treated cervix, cervical cancer.

2. Failure to select appropriate biopsy sites, enough biopsies, sufficient volume of tissue.

3. Failure to accurately record colposcopic findings

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C. In management

1. Miscommunication with the pathologist.

2. Failure to correlate cytology, colposcopy & histopathology.

3.Destructive therapy without biopsy, for invasive or glandular lesions.

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D. In the colposcopist

1. Inadequate training. 2. Inadequate experience. 3. Inadequate understanding of the disease. 4. Failure to keep up with scientific developments 5. Failure to maintain skills. 6. Failure to seek consultation.

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Diploma of colposcopy

•No one should be allowed to practice colposcopy

without having proper training or without a diploma

in colposcopy

(Jordan,1995).

•It would be a legal document that would safeguard

the public & raise the status of the colposcopist.

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Future research in colposcopy

(Hilgarth,1998)

1. Computerized colposcopic documentation &

consecutive analysis of colposcopic findings.

2. Clinical significance & biologic behavior of minor

lesions visible with colposcopy in the presence of

different HPV types.

3. Clinical significance & relation to HPV infection of

minor lesions beyond the TZ.

4. Vulvar lesions in vulvodynia related to HPV

infection. ABOUBAKR ELNASHAR

Future of colposcopy

(Niekerk,1998)

1. There are going increasing costs of medical care

& the demand for better quality control will

intensify.

2. Technical advances will revolutionize this area &

digital imaging, the storage of up to 4.500 images

on an optical disk & rapid teletransmission of

images will become practical..

The use of these new technologies for better &

more cost effective patient care is the challenge we

will have to meet in the 21st century.

ABOUBAKR ELNASHAR

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