Colposcopy permits examination of the vagina and cervix with a colposcope, an endoscopic instrument with a magnifying lens. The colposcope is also used to examine male genital lesions suspected in sexually transmitted diseases, condylomas, or human papillomavirus. Indications for this procedure in women include abnormal Papanicolaou (Pap) smear results or other cervical lesions, leukoplakia, and other cancerous lesions. Biopsy specimens and cell scrapings are obtained under direct visualization. Colposcopy can be used to assess women with a history of exposure to diethylstilbestrol (DES) in utero, born between 1938 and 1971 (referred to as DES Daughters) who are at an increased risk of developing a rare form of vaginal and cervical cancer called clear cell adenocarcinoma. Advantages of colposcopy include the following:
Lesions can be localized and their extent determined.
Inflammatory processes can be differentiated from neoplasia.
Invasive or noninvasive disease processes can be differentiated.
Colposcopy cannot readily detect endocervical lesions. Cervicitis and other changes can produce abnormal findings. When combined with findings from Pap smears, colposcopy can be a means of enhancing diagnostic accuracy. Tables 12.1 and 12.2 present correlation of findings and advantages and disadvantages of Pap smears and colposcopy. See Chapter 11 for Pap smear procedure.
Whitish areas of epithelium (squamous cell hyperplasia, formerly called leukoplakia), mosaic staining patterns, irregular blood vasculature, hyperkeratosis, and other abnormal-appearing tissues can be seen using colposcopy. The colposcope has a definite advantage for detecting atypical epithelium, designated in the literature as basal cell activity. Atypical epithelium cannot be called benign and yet does not fulfill all criteria for carcinoma in situ. Its early detection promotes cancer prophylaxis.
Patients receiving colposcopy may often be spared having to undergo surgical conization (the removal of a cone of tissue from the cervix).
A hysteroscopy is the visualization of the uterus and fallopian tubes with the use of a hysteroscope, an endoscopic instrument. The cervix, cervical canal, and vagina may also be examined. The procedure may be performed to determine the cause of abnormal uterine bleeding, size and shape of the uterine cavity, location of a misplaced intrauterine device, and uterine abnormalities. Removal of polyps, adhesions, and other procedures may also be performed during a hysteroscopy. A local anesthetic is usually administered into the cervix and paracervical area before insertion of the hysteroscope; however, the procedure may also be performed using general anesthesia.
Place the patient in the modified lithotomy position. Expose the vagina and cervix with a speculum after the internal and external genitalia have been carefully examined.
For a colposcopy:
Swab the cervix, vagina, or male genital areas with 3% acetic acid as needed during the procedure to improve visibility of epithelial tissues (it precipitates nuclear proteins within the cells). Remove the cervical mucus completely. Do not use cotton-wool swabs because fibers left on the cervix interfere with proper visualization.
Begin actual visualization with the colposcope with a field of white light and decreased magnification to focus on sites of white epithelium or irregular cervical contours. The light is then switched to a green filter for magnification of vascular changes.
Diagram suspicious lesions and take photographs for the permanent healthcare record.
The transformation zone and squamocolumnar junction (where the squamous epithelium meets the columnar epithelium of the cervix) are areas where many women exhibit atypical cells. It is imperative that these zones be visualized completely, especially in older women, because of changes associated with aging.
For a hysteroscopy:
Insert the hysteroscope and inject fluid or gas into the uterine cavity to distend the uterus and improve visibility.
Obtain biopsy specimens of the lesions using a fine biopsy forceps. Some patients note discomfort at this time.
Place specimen in proper preservative, label accurately, and route to the appropriate department.
Endocervical curettage must be performed before colposcope-directed biopsy so that epithelial fragments dislodged during colposcopy do not cause false-positive results in the endocervical curettage. The endocervical smear (curettage biopsy samples) should be placed on a slide in formalin.
Sterile saline or sterile water should be used to cleanse and rinse acetic acid from the vaginal area to prevent burning or irritation. Bleeding can be stopped by applying toughened silver nitrate cautery sticks or ferric subsulfate (Monsel solution).
Inform the patient that a small amount of vaginal bleeding or cramping for a few hours is not abnormal.
A paracervical block (e.g., with lidocaine) may be necessary in patients who are extremely anxious.
Follow guidelines in Chapter 1 regarding safe, effective, informed intratest care.
Abnormal lesions or unusual epithelial patterns include the following:
Leukoplakia (white patches appear on mucous membranes of the urinary tract and genitals)
Abnormal vasculature
Slight, moderate, or marked dysplasia
Abnormal-appearing tissue is classified by punctation (i.e., sharp borders, red stippling, epithelium whiter with acetic acid), mosaic pattern (i.e., sharp borders, mosaic pattern, epithelium whiter with acetic acid), or hyperkeratosis (i.e., white epithelium, rough, visible without acetic acid)
Extent of abnormal epithelium (with acetic acid) and extent of nonstaining with iodine
Clinical cervical cancer, cervical exfetation pain (fetus developing outside of the uterus)
Acute inflammation with human papillomavirus or bacterial infections (e.g., chlamydia), bacterial vaginosis, and gonorrhea
Pretest Patient Care
Explain test purpose and procedure. Record preprocedure signs and symptoms (e.g., abnormal Pap, cervical, or vaginal drainage or bleeding).
Confirm that a signed informed consent is in the patient’s medical record.
Ensure that the patient has fasted for the required amount of time, if ordered.
Obtain a urine specimen and a pertinent gynecologic history.
Follow guidelines in Chapter 1 for safe, effective, informed pretest care.
Posttest Patient Care
Monitor for bradycardia and hypotension and treat accordingly. Have the patient sit for a short while before standing.
Monitor for complications, including heavy bleeding, infection, or pelvic inflammatory disease.
Instruct the patient to abstain from sexual intercourse and to not insert anything into the vagina for 2–7 days (per healthcare provider’s orders) after the procedure.
Warn the patient that slight vaginal bleeding may occur, but excessive bleeding, pain, fever, or abnormal vaginal discharge should be reported immediately. Advise the patient that ibuprofen may relieve cramps.
Review test results; report and record findings. Modify the nursing care plan as needed. Note that cervical scars from previous events may prevent satisfactory visualization and counsel appropriately regarding follow-up treatment such as cone biopsy and loop electrosurgical excision procedure. If radiation treatment is prescribed, cervical tumor tissue may be tested for the presence of glutathione as a possible indicator of radiation resistance.
Follow guidelines in Chapter 1 for safe, effective, informed posttest care. Provide written discharge instructions.