GYNAECOLOGICAL BIOPSIES

Vulval biopsy
Biopsy of vulval lesions is indicated in cases of leukoplakia, carcinoma (in situ or invasive) and condylomata. Occasionally, biopsy may identify tuberculosis or schistosomiasis as the cause of a lesion.

Place the patient in the lithotomy position and clean and drape the perineum. Administer a local anaesthetic by infiltration of 1% lidocaine. If the vulval lesion is large, excise a portion of it, ligate any bleeding vessels and approximate the skin. Excise small, localized lesions with a margin of healthy skin. Bleeding is a possible complication.

Cervix cytology

Use cytology for the diagnosis of precancerous lesions. A speculum, wooden spatulae and slides are required. Obtain cytological preparations from the ectocervix and endocervix. After introducing an unlubricated speculum, collect cells under direct vision by scraping with a wooden spatula. Make a smear on the glass slide and apply a fixative.

Cervical biopsy

The indications for cervical biopsy include chronic cervicitis, suspected neoplasm and ulcer on the cervix. Frequent symptoms are vaginal discharge, vaginal bleeding, spontaneous or postcoital bleeding, low backache and abdominal pain and disturbed bladder function. Speculum examination may reveal erosion of the cervix. In cases of invasive carcinoma, the cervix may initially be eroded or chronically infected. Later it becomes enlarged, misshapen, ulcerated and excavated or completely destroyed, or is replaced by a hypertrophic mass. Vaginal examination reveals a hard cervix which is fixed to adjacent tissues and bleeds to the touch. To rule out malignant infiltration, stain the cervix with Lugol’s iodine solution. A malignant area will fail to take up the stain.

Perform a punch biopsy as an outpatient procedure. Anaesthesia is not necessary. Place the patient in the lithotomy position, expose the cervix and select the most suspicious area for biopsy. Using punch biopsy forceps, remove a small sample of tissue, making sure that you include the junction of normal and abnormal areas (Figure 5.62). Possible complications include sepsis and haemorrhage. If bleeding is excessive, pack the vagina with gauze for 24 hours.

Figure 5.62

Cervical erosion

Cervical erosion is a misnomer for the bright red endocervical epithelium which extends to the ectocervix. It may be associated with contact bleeding. On examination, it is easily recognized as a bright red area continuous with the endocervix. It has a clearly defined outer edge but there is no breach in the surface. On digital examination, it feels soft with a granular surface which produces a grating sensation when stroked with the tip of the finger. It bleeds on touch.

Fix a cervical smear for cytological examination. If symptomatic, treat the lesion with electrocautery. Anaesthesia is unnecessary but a sedative is optional. With electric cautery, make radial stripes in the affected mucosa but leave the cervical canal untouched. There will be an increase in vaginal discharge after cauterization. Have the patient avoid coitus for 3–4 weeks. Possible complications include cervical stenosis (particularly if the endocervix has been inadvertently cauterized) and haemorrhage.

Endometrial biopsy

Perform endometrial biopsy in cases of infertility, to determine the response of the endometrium to ovarian stimulation. Carry out the procedure during the patient’s premenstrual phase. Place the patient in the lithotomy position and cleanse the perineum, vagina and cervix. Retract the vaginal walls, grasp the cervix with a toothed tenaculum, and pass a uterine sound. Insert an endometrial biopsy cannula and obtain one or two pieces of the endometrium for histopathological examination (Figure 5.63). Examine for the secretory changes that identify the cycle as ovulatory. Perforation of the uterus and postoperative sepsis are rare complications.

Figure 5.63

Polypectomy

Polypectomy is indicated for the treatment of cervical polyps and of pedunculated endometrial polyps that present through the cervix. Symptoms include vaginal discharge that is mucoid, mucopurulent or serosanguineous, contact bleeding, menorrhagia, intermenstrual bleeding and discharge and uterine colic. Many cervical polyps remain symptomless and are discovered only on routine examination. On speculum examination, a polyp appears through the cervical os as a dull, red and fragile growth. On vaginal examination, it is felt as a soft, fleshy mass that bleeds on touch. Differential diagnosis includes carcinoma and sarcoma botryoides. A polyp can also be confused with extruded products of conception.

Place the patient in the lithotomy position and clean and drape the area. Expose the cervix and grasp its anterior lip with a toothed tenaculum (Figure 5.64).

Figure 5.64

Grasp the polyp with sponge forceps and remove it by ligating and then cutting the stalk (Figures 5.65, 5.66, 5.67).

Figure 5.65

Figure 5.66

Figure 5.67

Follow the polypectomy by dilatation and curettage with the patient under anaesthesia (see pages 12–18 to 12–19. Look for any other intrauterine source of discharge, such as carcinoma, and treat additional polyps in the cervical canal or the body of the uterus. Send specimens for histological examination.