chapter 5. Equipment for a colposcopic examination CHAPTER 1 CHAPTER CHAPTER 5 CHAPTER This chapter describes the which allows the colposcope head to interference. Any shorter and it is equipment needed to perform a col- be placed more precisely and with- difficult to use handheld instruments poscopic examination and its more out interfering with the operator’s under direct colposcopic view; any common uses in clinical practice. comfort. There are a large number of longer and it is too far to comfortably A step-by-step description of the colposcopes on the market. Fig. 5.1 technique and how to shows a typical colposcope mounted Fig. 5.1. A typical colposcope with a optimize the examination follows in on a floor stand. movable base. Chapter 6. Certain instrument character- istics should be considered before 5.1 Colposcope buying a colposcope. It must be binocular, so that depth of field may The colposcope is a relatively simple be appreciated. This is particularly instrument that allows examination important when performing exci- of the under light illumination sional treatment and when trying to at various low-power magnifications. assess surface contour and perform It consists of a binocular examination of endocervical epitheli- and light source, often incorporating um (Carcopino et al., 2014). The lens a beam splitter to allow attachment should have a focal length of 30 cm, of a still or video camera. It may ei- which is short enough to allow the ther be attached to a central upright examiner to reach the cervix with in- rigid bar, as in the original colpo- struments, swabs, and spatulas and scope introduced in Germany in the yet long enough to allow the colpos- 1920s, or be connected to a weight- copist’s hands to move between the ed stand with an adjustable arm, colposcope and the cervix without

Chapter 5. Equipment for a colposcopic examination 37 Fig. 5.2. Two views of the colposcope head, showing the two eyepieces (e), entire cervix in one field, especially the magnification changer (m), the camera access port (c), and the 30 cm during treatment. A good colposcope lens (l). Coarse focus is attained by moving the entire colposcope head. will have a low enough magnification Fine focus is achieved using the fine focus handle (f). setting to allow this (i.e. 4×). Three or four different magnifications between e 4× and 15× are ideal. Rapid change m from one magnification to another is effected with a simple knob (the c magnification changer). For coarse focus, the colposcope head can be l moved manually, and for fine focus, there is a separate knob. f Before starting a colposcopic examination, one should first con- reach the cervix. The colposcope lamps last longer. Most colposcopes firm personal visual acuity settings, head must be universally movable have a green filter, which takes away in other words that the colposcope and should be easily fixed once in the background redness so that the is set up properly for the examiner’s position, so as to allow the colposco- vessels appear black and fine ves- eyes (see Chapter 6). It is prudent to pist freedom of hand movement. A sel changes may be more easily do this while looking at an inanimate camera attachment (and therefore a appreciated. object at the beginning of a clinic beam splitter) is very useful for both Also, most colposcopes have session, before a patient undresses. training and documentation. a magnification changer, although Colposcope manufacturers near- The colposcope head (Fig. 5.2) some are variable and allow a zoom ly all supply a camera, monitor, and comprises an objective lens; two capacity. In practice, it is rarely nec- computerized image storage and da- eyepieces, which may be adjusted to essary to examine at a greater mag- tabase package. Fig. 5.3 illustrates each person’s eye position and may nification than 15×. There is a trade- an integrated colposcopy system. be focused independently; and a off. At greater magnification, the field light source, which in the instrument of view diminishes, the depth of fo- 5.2 Gynaecological couch shown comes from a light cable at- cus decreases, and the light required and operator’s stool tached to a light source. Halogen increases. At higher magnifications, lights are very powerful, are easily it is sometimes easier to appreciate For most women, any gynaecolog- replaced, and are relatively inex- fine vessel changes. However, it is ical examination couch (Fig. 5.4) pensive. Light-emitting diode (LED) important to be able to visualize the that allows the patient to adopt the

Fig. 5.3. A colposcope with inte- Fig. 5.4. A colposcopy/ gynaecological examination couch. It grated video camera, monitor, and may be elevated and flattened independently. A waste receptacle is fitted data collection system attached to just below the patient’s perineum. the colposcope’s movable stand.

38 lithotomy or semi-lithotomy position to an electrosurgical unit (ESU) has been performed, and also as an may be used to perform colposco- (Fig. 5.5). The loop electrode is educational tool for attending colpos- py. However, it is important that the housed in a so-called pencil. Suc- copy trainees. base of the couch may be tilted so tion tubing will connect the ESU to that the TZ on the cervix will become the , and a ground 5.4 Computerized data almost perpendicular to the colpo- plate will connect the patient to the management system scopic line of vision. The back of the ESU. Some ESUs have a suction couch should also be adjustable, unit incorporated into the unit; others Many companies provide a software and it should be possible to easily do not, in which case it will be nec- package that allows sociodemo- elevate or lower the whole couch. A essary to have a separate suction graphic, clinical, colposcopic, and comfortable couch is hugely impor- machine. The equipment for LLETZ/ laboratory data and image capture tant for the patient, who will need to LEEP, thermal coagulation, and cryo- as well as automatic audit of colpo- be in position for several minutes in is described in Chapter 11. scopic diagnostic performance. In relative undress and who is very like- this way, it is relatively easy to cre- ly to be anxious. It is important to be 5.3 Camera system ate a full audit of performance for an able to elevate or lower and tilt the individual colposcopist and to main- couch to allow optimal positioning Almost all of the major camera com- tain a clinical database for the clinic of the patient. Also, an examiner’s panies will supply a camera and at- service. However, the programs are stool that can be elevated or lowered tachment for a colposcope. Unfortu- expensive. is very helpful. Being able to quickly nately, the colposcopes usually need flatten the couch so as to deal with a C-mount for the camera to attach 5.5 Instrument trolley the rare vasovagal attack is impor- to the colposcope, and C-mounts tant. Finally, the same couch may be are expensive. Many modern colpo- An instrument trolley may seem an used for most outpatient gynaeco- scopes have a camera system incor- unnecessary luxury in colposcopy logical procedures (e.g. hysterosco- porated into the instrument, without clinics where budgets are tight. How- py, intrauterine contraceptive device the need for a C-mount. Nowadays, ever, the reusable and disposable [IUCD] insertion, and transvaginal the cost of a reasonable video cam- equipment and the fluids needed to ultrasonography). era is almost the same as that of a perform a proper colposcopic ex- CHAPTER 5 CHAPTER If a decision is made to perform still image camera, and very high amination have to be housed some- excisional treatment, it should usu- quality video images can be obtained where, and to have them all to hand ally be performed as an outpatient and stored for future reference. This in one compartmentalized trolley procedure using electrosurgery to is immensely valuable as a clinical is both efficient and ergonomically resect the TZ , i.e. LLETZ/ aid in following up screen-positive sensible. The last thing a colposco- LEEP. A loop electrode is attached patients, whether or not treatment pist or the patient needs is to have to wait for an assistant to find a par- ticular instrument when it is needed. Fig. 5.5. A portable, battery-driven electrosurgical unit incorporating a Finally, if instruments are not housed suction unit. Ports for the electrosurgical pencil and the ground plate are displayed. A simple electrical battery charger access point and the on/off in a compartmentalized trolley they switch complete the display at the front. The suction port site is at the rear are not within arm’s length of the of the unit. colposcopist, and they should be. Figs. 5.6–5.8 illustrate how some reusable instruments and some dis- posable equipment may be conve- niently housed in a trolley. The con- tents of the top, middle, and bottom drawers are shown in Figs. 5.6, 5.7, and 5.8, respectively. In Fig. 5.9, the top surface of the trolley shows some instruments laid out for a colposcop- ic examination. A needle disposal box and a fluid tray are attached on the side (Fig. 5.10).

Chapter 5. Equipment for a colposcopic examination 39 Fig. 5.6. Open top drawer of a colposcopy clinic trolley, Fig. 5.7. Open middle drawer of a colposcopy clinic which conveniently stores in adjustable compartments trolley, which stores a variety of disposable examination a variety of disposable equipment: lubricating jelly, gloves, gauze swabs, and cotton balls. chlorhexidine gluconate sachets, cork boards for specimen pinning, dental syringe needles, culture swabs, cotton swabs and jumbo swabs, endocervical smear brushes, and cytology fluid bottles.

Fig. 5.9. Top surface of the equipment trolley used in many colposcopy clinics. Some of the equipment used during a colposcopic examination and treatment are laid out on an incontinence pad. These include cotton swabs and jumbo swabs, a sponge and cotton balls, Fig. 5.8. Open bottom drawer of a colposcopy clinic a suction speculum of medium size, some dental vials trolley, which stores colposcopy suction specula of three containing local analgesic fluid for injection using the different sizes. dental syringe system, and a loaded dental syringe.

5.6 Reusable instruments the perpendicular plane, and a tube on the underside of the anterior speculum that is too large will hurt blade (Fig. 5.11a). Insulated specu- 5.6.1 Specula the patient. Parity and bimanual ex- la are to be avoided, even if using amination will reveal the appropriate diathermy. After several steriliza- It is fundamentally important to have speculum to be used for colposcopy. tion cycles, the insulated speculum a full set of different sized specula Specula may be metal or plastic. If can lose some of its covering, and available when performing colposco- LLETZ/LEEP or a “small loop” di- this may not be noticeable to the py. A speculum that is too small will agnostic biopsy is to be performed, naked eye. If this happens, an elec- not comfortably expose the cervix in the speculum should have a suction trical contact could indeed burn the

40 Fig. 5.10. On the side of the equipment trolley are attached a needle disposal IFCPC nomenclature (Bornstein et box and a receptacle for the and Lugol’s spray bottles. al., 2012b) as a type 1 TZ. The type 2 TZ, by definition, has an endocervi- cal component but is fully visible to the examining colposcopist. To ac- curately determine the TZ type, it is necessary to carefully examine the SCJ as fully as possible. Also, when investigating a suspicion of adeno- carcinoma or glandular precancer, it is necessary to examine the en- docervix. This will usually require the use of an endocervical forceps. There are several good ones on the market. User-friendly ones are the Kurihara and the Desjardins forceps, which are shown in Fig. 5.12.

5.6.4 Local analgesia (dental) syringes patient’s . With the uninsulat- Others prefer spray bottles, which Metal dental syringes house 2.2 mL ed speculum, no such risk arises. may be less cumbersome (Fig. 5.10). vials of either prilocaine with fely- The area of contact with the vaginal If the spray bottles are used, it is im- pressin or lignocaine with adrenaline. skin is so large that burns are ex- portant to be aware that splashback They allow attachment of 27-gauge tremely unlikely even if contact with can occur and to protect one’s eyes needles, which automatically punc- the loop or ball electrode happens from exposure either with glasses or ture the vials when they are loaded accidentally. Also, if one ensures with the colposcope. into the dental syringes, ready for CHAPTER 5 CHAPTER that LLETZ/LEEP is performed at use. They allow exchange of empty low-power magnification, the entire 5.6.3 Endocervical forceps vials for new, full ones in a matter of loop should be visible before and seconds, so that complete local an- during the procedure, so that con- The epithelium that is at risk of de- algesia may be achieved in less than tact with the vagina or speculum is veloping squamous a minute (see Chapter 2). A loaded extremely unlikely. Occasionally, the is usually on the ectocervix in young dental syringe is shown in Fig. 5.13. patulous parous vagina is so lax that women, and this is defined in the The loaded syringe is long enough to it is not possible to completely visu- alize the cervix with the colposcope. Fig. 5.11. (a) A Cusco speculum with a suction tube on the underside of Although lateral vaginal wall retrac- the anterior blade for smoke evacuation. (b) A condom (with its end cut off) tors are available to attach to some placed around a Cusco speculum to facilitate examination when the vaginal specula, they are relatively uncom- walls are exceptionally patulous. fortable; a condom (Fig. 5.11b) or the finger of a large glove (with its end a b cut off) is a simpler and often more effective alternative.

5.6.2 Sponge forceps

Colposcopists vary in their choice of method for applying acetic acid or Lugol’s iodine. Some use cotton balls soaked in the fluid and applied using a sponge forceps (Fig. 5.9).

Chapter 5. Equipment for a colposcopic examination 41 Fig. 5.12. (a) Kurihara forceps. (b) Higher-magnification view of Desjardins Tischler-Morgan forceps. When per- forceps. forming , some colposco- pists use infiltration of local analge- a b sic, and some do not. A small, long hook may be used to fix the cervix before taking a biopsy, but it is not usually necessary if the biopsy for- ceps instrument is sharp. Fig. 5.15 shows a small loop, which is a con- venient way of taking a diagnostic biopsy. Fig. 5.16 shows a range of loops that are used for taking biop- Fig. 5.13. Loaded dental syringe. Fig. 5.14. Punch biopsy forceps. sies as well as for excising the TZ. Fig. 5.17 shows a ball diathermy electrode, used to achieve haemo- stasis after excision of the TZ or to seal a biopsy site. Other haemostatic agents include Monsel’s paste (see Annex 5) and sticks. easily reach the cervix, and because the USA but are not often used in 5.7 Disposable equipment the needle itself is relatively short, it the United Kingdom. Many patients will not bend sufficiently to cause a find an endocervical to be Either a 3% or a 5% concentration of problem with infiltration. Finally, it is uncomfortable; it often produces in- acetic acid may be used to highlight narrow enough not to obscure colpo- adequate material and usually pre- colposcopically recognized epithelial scopic vision during infiltration. cipitates bleeding. It rarely influenc- lesions. There is no evidence to sug- es practice, and a good endocervical gest that one strength is superior to 5.6.5 Tissue sampling brush smear sample is considered the other, although some authorities instruments a superior method by many. Biopsy say that the 3% concentration takes a forceps (Fig. 5.14) need to be sharp little longer to effect whiteness. What The threshold for taking a biopsy if they are to procure adequate biop- is important is that the same concen- varies from one setting to another. sies, and some manufacturers make tration is used for all patients. Care In some colposcopy clinics a biopsy disposable forceps or disposable is needed in preparing the solution; is considered mandatory for every cutting parts for the reusable biop- disasters have occurred with glacial examination, whereas in others a sy forceps handles. The common acetic acid, which will de-epithelial- “see-and-treat” policy prevails for ones available are the Kevorkian and ize cervical and vaginal epithelium. women with convincing evidence of high-grade dysplasia (see Chap- Fig. 5.16. An array of loops used Fig. 5.17. A ball diathermy electrode, ter 1). Endocervical are for LLETZ/LEEP of different sizes used to achieve haemostasis after routinely used in many practices in and types of transformation zone, excision of the transformation zone and cervical biopsy loops (pink and or to seal a biopsy site. Fig. 5.15. A small loop used to take green) used for taking diagnostic colposcopically directed biopsies us- biopsies. ing an electrosurgical unit.

42 Lugol’s iodine stains mature is trying to recognize or rule out the board (Fig. 5.18) before immersion squamous epithelium dark mahoga- presence of intraepithelial neoplasia, in formalin, so that it may be sec- ny brown and affects immature and punch biopsy forceps are adequate, tioned longitudinally and an accu- dysplastic epithelium variably (see but if one is concerned about inva- rate assessment of the SCJ may be Chapter 8). Saline is advocated by sive disease, a small loop electrode reported. several authorities as a cleaning (Figs. 5.15 and 5.16) should be con- agent before the application of acetic sidered, because it allows a greater Fig. 5.18. Cork board and pins to acid or Lugol’s iodine. Cotton swabs depth and confidence in revealing mount LLETZ/LEEP specimens. are useful to manipulate the cervi- the basement membrane at histolog- cal epithelium, and jumbo swabs ical examination. or cotton balls are alternatives (to spray bottles) for the application of 5.8 Cork boards and pins acetic acid or Lugol’s iodine. If treat- to mount LLETZ/LEEP ment is contemplated, 27-gauge specimens dental syringe needles and vials of prilocaine with felypressin or ligno- Liaison with one’s local laboratory caine with adrenaline are needed, will determine in which way excised and various biopsy forceps or small LLETZ/LEEP specimens will be re- loops are used to take colposcop- ceived. One option is to open the ically directed biopsies. When one specimen and then pin it onto a cork

Key points • Certain instrument characteristics should be considered before buying a colposcope.

• The gynaecological examination couch should be adjustable, so that it can be elevated or lowered and tilted to allow optimal positioning of the patient. CHAPTER 5 CHAPTER

• Video and/or still images are very valuable as a clinical aid and as an educational tool.

• Reusable instruments and disposable equipment may be conveniently housed in a compartmentalized trolley.

Chapter 5. Equipment for a colposcopic examination 43