Training Module 1

Unaided Visual Inspection of the Cervix

"Clinical Downstaging"

Saloney Nazeer

WHO Collaborating Centre in Education and Research in Human Reproduction

• Cervical Cancer Screening: Training Modules
• Picture Atlas

Objective

The objective of the visual inspection is solely to be able to recognize clinically normal from abnormal cervix and refer abnormal looking cases for further evaluation and diagnosis and appropriate treatment.

The aim is to detect cervical cancer at an early stage in asymptomatic women, to improve their prognosis. It can also be used to selectively screen women who would require a Pap-smear, where that facility is available, albeit in limitation.

Equipment required

1. Examination table, preferrably with stirrups
2. Sterile speculum, preferably Cusco's
3. Sterile rubber gloves
4. Source of light, a lamp or a torch
5. Cotton swabs
6. Forceps
7. Stationary, to record examination findings

The Examination

1. The procedure and the reason for it should be carefully explained to the woman to be examined and she should be made as comfortable as possible. Take into consideration the privacy of the patient.
2. Put patient in lithotomy position (if possible) or suppine with legs bent at knees
3. Good visualization is essential. Direct the light source to the genital area.
4. Observe and record any abnormal findings in the external genitalia.
5. Lubricate the speculum with warm water and insert into the vagina with the speculum closed.
6. Open the speculum and adjust the light source so as to get a clear view of the cervix.
7. If there is excess mucus or discharge, clean it with a cotton swab soaked in boiled water or normal saline solution.

Important: Do not perform the examination if the woman is having menstrual period or is using intravaginal medication. Advise her to come back when the mensus or the treatment is over.

Reporting Visual Inspection Findings

The gross appearance of the cervix should be classified as follows:

Classification	Appearance of the Cervix (see Atlas)
Normal	Smooth, pink Clear mucoid secretion Central hole-'external os' Nulliparours-round Multiparous-slit or criciate Cervix in postmenopausal women is atrophic
Abnormal Clinical interpretation: Can be; Infection Ectopy (erythroplasia) Benign tumour	Hypertrophy Redness or congestion Irregular surface Distortion Simple erosions (do not bleed on touch) Cervical polyps (with smooth surface) Abnormal discharge: foul smelling, dirty/greenish, cheesy white, blood stained Nabothian follicles Prolapsed uterus
Suspicious of Malignancy	Erosion that bleeds on touch or friable Growth, with an irregular surface or friable

Important: All findings, normal or abnormal, should be carefully recorded in the provided printed form. The patient should be informed and explained the follow-up procedure accordingly.

Referral Protocol

1. Normal cervix: follow-up after 2-3 years according to the decided policy. Advise to come back if develops symptoms.

2. Abnormal cervix: (no suspicion of malignancy):
   If infection is suspected, take a swab and send for analysis. Refer the patient to the primary health clinic (PHC) for further evaluation and treatment.

   At the PHC:

• If signs of infection are present, treat the patient accordingly. Re-examine after six weeks.

• If no signs of infection. Perform Pap-smear and send for analysis. Follow-up cytology results in 1-2 weeks and inform patient accordingly.
  • Pap-smear negative: re call after 2-3 years for visual inspection
  • Pap-smear positive: call the patient for appropriate treatment.

3. Suspicious of Malignancy: Refer directly to oncology/tertiary care facility for appropriate assessment and treatment. Do not perform Pap-smear.

Visual Examination Reporting Form

See Annex.