Prof. Aboubakr Elnashar
Benha University Hospital. EGYPT
•The colposcope was first developed in
1925 & is well established in
gynecologic practice for defining &
delineating cytologically detected
lesions mainly of the cervix but also the
vagina & vulva.
•Colpscopy is now gradually spreading
allover the world & postgraduate training
courses is now being given in many
Historic events related to colposcopy
1925: Invention of colposcope(Hinselman)
1928: Schiller test
1938: Acetic acid test (Hinselman)
1939: Green filter (Kratz)
1940: Pap test
1942: First photographs of cervix (Treite)
1980: Laser surgery
1988: Computer-aided colposcope
1989: LLETZ (Prendiville & Cullimore)
1991: Pap Net
2000: Telecolposcopy ( Harper et al)
• New optical lenses, fiberoptic light cables &
videocameras with digital computer
enhancement, all played a part in advances
•Computer technology has made it possible
to capture images directly onto a computer &
these images allow enhancement &
manipulation according to physician,s
Digital imaging colposcopy
(CCD=charge couple device)
Colposcope Optical interface
Video digitizer Video monitor
Mass storage Personal computer Printer
Telecolposcopy ( Harper et al,2000)
*Telecolposcopic system incorporating
a custom software package.
*All images were received without
distortion in color, size, or orientation.
is technically feasible,
can be implemented in an office system
with limited technical support & is
preferred by women who have to travel
many miles to receive referral health care.
Current indications of colposcopy
1. Part of any gynecologic examination
2. Primary screening for cervical cancer.
3. Clinically suspicious cervix.
4. Abnormal Pap smear.
5. Evaluation & treatment of CIN.
6. Follow up after conservative therapy of CIN.
7. Postcoital bleeding.
8. Patients with external vulval warts
9. Evaluation of sexual assault victims.
10. Patients with history of DES exposure
•Screening colposcopy is a feasible procedure &
more sensitive & more cost effective than
cytological screening. When access to
cytopathology is difficult, screening colposcopy
is an alternative (Cecchini et al,1997).
•Portable colposcopy in rural areas is cost
effective & highly acceptable (Martin et al,1998).
•The colposcopy improved detection of genital
trauma in adult female sexual assault victims as
compared with gross visual examination alone
Recent recommendations of FIGO for management of abnormal
Persistent inflam., persistent ASCUS, LSIL, HSIL, AGCUS,Invasive
Normal or LSIL HGSIL Invasive
6 mo smear x 2 LEEP Appropriate TT
• Lugols’iodine test: beneficial test..
• ECB has replaced ECC: easier to use, malleable & less
Its specificity 92%, sensitivity 90% & positive predictive
value 88% ( Martin et al, 1995).
• Punch biopsy: False negative rate up to 54% ( Buxton
Excisional techniques are superior to destructive
1. Vascular pattern. 2. Inercapillary distance
3. Contour. 4. Color
5. Clarity of demarcation
6. Appearance of gland opening.
7. Negativity after iodine test
8. Whiteness after acetic acid:
Density of whiteness, time needed to appear &
Changes >35 yr are thinner & less demarcated., punch
biopsy (Zahm et al, 1998).
9. Surface extent of the lesion: more important
prognostic indicator for invasion than histological
grading ( Tidbury et al,1992)
International Federation of Cervical Pathology &
Normal: Original squamous epithelium
Normal transformation zone
Abnormal: Acetowhite epithelium Punctation
Iodine negative Atypical vessels
Suspect invasive cancer:
Unsatisfactory:SCJ not visible, severe inflam or atrophy, invisible cervix
Miscellaneous:Nonacetowhite micropapillary surface,
exophytic condyloma, inflammation, atrophy, ulcer
Low grade High grade
•Acetowhite epithelium: shiny or snow dull, oyster white color
•Surface: flat irregular contour, microexophytic
•Demarcation: diffuse, irregular, sharp, straight line,
internal demarcation absent internal demarcation present
•Vessels: fine, regular shape, uniform coarse, dilated, increased ICD,
caliber, normal arborization, spaghetti bizarre, commas, corkscrews
changing calibers sharp bends
•Iodine: uniform mahogany brown mustard yellow, yellow or iodine -ve
Update of colposcopy of genital HPV
Meisels et al (1982): Florid, spiked, flat, condylomatous .
Flat condyloma & mild dysplasia represent the same
biologic phenomenon, namely, productive HPV infection
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.
Micropapillary condyloma should not be confused with
Colposcopy of the vulva
1. Examination after smearing with a water
2. Prolonged acetic acid test
3. Toludine blue test: little clinical value.
* 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.
Update on colposcopy in pregnancy
Difficult. & reserved for the most experience
Reassurance of the patient.
ECC is contrindicated & one directed biopsy.
Large speculum is usually needed
Sponge forceps to remove the mucous & acetic acid a
Unsatisfactory colposcopy: repeat after 8 w
The aim is to exclude cancer
CIN: follow up & definitive treatment 1-2 m
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.
B. In diagnosis
1. Misinterpretation of exagerated patterns of
pregnancy, previously treated cervix, carvical cancer.
2. Failure to select appropriate biopsy sites, enough
biopsies, sufficient volume of tissue.
3. Failure to accurately record colposcopic findings
C. In management
1. Miscommunication with the pathologist.
2. Failure to correlate cytology, colposcopy &
3.Destructive therapy without biopsy, for invasive
or glandular lesions.
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.
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.
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.
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.
Benha University Hospital. EGYPT