A bimanual exam should have been done with the annual exam. If a bimanual examination is needed, perform it here. Quickly examine the vulva for obvious condylomata or other lesions. If cervical biopsy is well tolerated and things are going well, examine the vagina/vulva after the biopsies as the speculum is withdrawn. The excess vinegar from the cervical exam will often stain the vulva. The vulva also can be examined at the time your patient returns for follow-up and/or definitive treatment.
Apply 5% acetic acid with a cotton ball held in a ring forceps or a rectal swab. This gently applies lots of vinegar quickly and without trauma. Repeat application every five minutes, as the vinegar effect is only temporary. Warn patients, "this may burn a little." Calling the solution "acetic acid" may help increase the patient's perception of burning. Calling it "vinegar" usually will not.
Start with low power (typically 5x). Scan the entire cervix with
white light. Use a vinegar-soaked Q-tip to help manipulate the cervix
and transformation zone into view if necessary. The tenaculum is
almost never necessary to move the cervix. Kogan endocervical speculum
can greatly aid the examination of the distal endocervical canal if necessary.
Use higher magnification to carefully document abnormal vascular patterns.
The green filter can help find vascular areas.
May be used by the beginning colposcopist or at any time when further
clarification of potential biopsy sites is necessary. It need not
be used in all cases. The sharp outlining afforded by Lugol's iodine
(Schiller's test) can be dramatic and very helpful. Iodine staining
does not interfere with histology. Lugol's solution is often very
helpful on the vagina and proximal vulva (non-keratinized skin).
It can be used to thoroughly and simultaneously examine the entire vagina
for glycogen-deficient areas, which correlate with HPV and/or dysplasia
in non-glandular mucosa. It is often reserved for difficult cases
when a non-cervical source of cervical Pap smear atypism is suspected (as
in "normal cervical colposcopy" with dysplasia on Pap smear or normal ECC
histology).
Perform an endocervical curettage (ECC) or endocervical brushing (ECB) if indicated.
Use a Kevorkian curette (preferably without a basket) and scrape the canal, 360 degrees, twice. The sample appears as a coagulum of mucus, blood, and small tissue fragments. Use ring forceps or a cytobrush to gently retrieve the sample. Submit on paper and label "ECC." Do not do an ECC on pregnant patients. Alternatively, a cervix Pap smear brush (the "pipe-cleaner type brush") may be placed into the os and spun around 5 times. The resulting tissue and blood coagulum may be submitted as a histological specimen in formalin. A short drinking straw may also be placed over the brush to act as a sheath to protect the brush from contamination by the ectocervix while the device is being introduced or withdrawn. Place the brush inside of the straw and place the straw against the os. Then advance the brush, obtain the sample, and withdraw the brush back into the straw for removal. This results in sensitivity about the same as the Kevorkian curette but a higher specificity.
Apply pressure and Monsel's solution to bleeding sites. The Monsel's should be as thick as toothpaste to be most effective. Swab out the excess Monsel and blood debris, which appears as a nasty black substance that eventually will pass and may cause alarm (and potential late night phone calls).
Gently remove the speculum and view the vaginal wall collapse around the receding blades of the speculum. Are any abnormal areas apparent? Have the patient rest supine for at least several minutes and then sit up slowly and rest again. Fainting and light-headedness are not uncommon.
Carefully draw and label a picture of lesions and biopsy sites.
Correlate the pictures with the submitted samples, if placed in different
containers.