Chapters

Introduction

Introduction

Visual inspection after application of acetic acid (VIA)

VIA as a screening test for cervical cancer Advantages of VIA Limitations of VIA VIA to triage women positive on the HPV test

Determining eligibility for ablative treatment after application of acetic acid

In the context of VIA screening In the context of HPV screening

Anatomical considerations

Anatomical considerations Gross anatomy of female genital organs

External genitalia Internal genitalia

Gross anatomy of cervix

Cervical epithelium

Cervical epithelium Squamous epithelium Columnar epithelium Squamocolumnar junction

Physiological changes of cervical epithelium

Ectropion Squamous metaplasia Transformation zone of the cervix Pregnancy Atrophic changes Congenital transformation zone (CTZ)

Neoplastic changes of the cervical epithelium

Genesis of cervical cancer Cervical intraepithelial neoplasia (CIN) Adenocarcinoma in situ (AIS) Cervical cancers

Changes in the cervical epithelium after application of acetic acid

Pathophysiological basis

Instruments, consumables, and setup required for examination after application of acetic acid

Instruments and consumables required Preparation of 5% dilute acetic acid Setup for the procedures

VIA procedure

As a screening test or a triage test Counselling History taking Preparation for VIA procedure Steps for inspection of the external genitalia Steps for insertion of the speculum and exposure of the cervix Steps for examination before application of acetic acid

Steps Normal findings

Normal cervicovaginal discharge Bleeding through the external os Nabothian cyst Ectropion

Abnormal findings

Cervicovaginal inflammation Cervical Polyp Leukoplakia Cervical condyloma Growth or ulcer

Examination after application of acetic acid

Steps for applying acetic acid to the cervix Detecting changes in the cervical epithelium after application of acetic acid Normal findings

Squamous epithelium Columnar epithelium Squamocolumnar junction (SCJ) Transformation zone (TZ)

Features during pregnancy Abnormal features

Abnormal features Rapidity of onset of acetowhitening Intensity of acetowhitening Margin of acetowhite area Location of acetowhite area Surface of acetowhite area Size of acetowhite area Conclusion of examination Post-VIA counselling Documentation of findings

Interpretation of VIA test results

Interpretation of VIA test results VIA Negative

No acetowhite area Columnar epithelium appearing white Polyps with faint acetowhite change Nabothian cysts appearing white Line-like acetowhitening at the SCJ Patchy acetowhite areas without any definite margin Thin acetowhite areas with tongue-shaped projections towards the external os Acetowhite areas away from the SCJ

VIA Positive

Dense acetowhite areas in the TZ with well-defined margins Dense acetowhite area on columnar epithelium Entire cervix appearing dense acetowhite Leukoplakia becoming acetowhite CTZ appearing acetowhite

Suspicious of invasive cancer

Preventing errors in VIA

Preventing errors in VIA Inadequate exposure of the cervix Inadequate visualization of the transformation zone Inadequate visualization of the margins of acetowhite areas Errors in assessment

Errors in assessment of acetowhite areas Errors in recognizing cervical cancer Errors in assessment of the postmenopausal cervix

Management of women with an abnormal VIA test

Management of women with an abnormal VIA test

Steps to determine eligibility for ablative treatment

Principles Principles of treating cervical precancerous lesions Criteria used to determine eligibility for ablative treatment Steps to determine eligibility for ablative treatment

Role of Lugol’s iodine in identifying the transformation zone for treatment

Role of Lugol’s iodine in identifying the transformation zone for treatment Steps for applying Lugol’s iodine to the cervix Lugol’s iodine for pre-treatment assessment Preparation of Lugol’s iodine

Treatment by cryotherapy

Principles Cryosurgical unit Ancillary instruments and consumables Steps Side-effects and complications Post-treatment advice and follow-up Video

Treatment by thermal ablation

Principles The benchtop model The battery-operated model Complications Video

Videos

Steps of applying acetic acid for VIA and identifying the transformation zone (VIA negative) Steps of applying acetic acid for VIA, determining eligibility for ablation and treatment with thermal ablation

Preparation of Monsel’s solution

Preparation of Monsel’s solution

Infection prevention

Standard procedures for protection from infection Essential steps for infection prevention in VIA screening or triage Preparation of 0.5% chlorine solution

VIA-negative cases VIA-positive cases VIA-suspicious of cancer cases

Quiz Acknowledgement Suggested citation Copyright

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Atlas of visual inspection of the cervix with acetic acid for screening, triage, and assessment for treatment

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Visual inspection after application of acetic acid (VIA) – Advantages of VIA

VIA has several advantages as a screening test or a triage test suitable for resource-limited settings. Traditionally, the Pap smear (cytology) has been the screening test of choice both in high- and low-resource settings. However, cytology-based screening has the following limitations:

The test sensitivity (the ability of the test to correctly identify the true positives, i.e. those with high-grade cervical precancer or cancer) is at best moderate (~50%) and can be very low in laboratories that do not have a robust quality assurance process.
The test is subjective, and the quality depends a lot on the training and expertise of the cytotechnicians or the pathologists.
Cytology requires laboratory infrastructure, well-trained technicians and pathologists, and stringent quality control at all steps.
The test results are not immediately available and may be delayed by a few weeks to a few months if there are not enough technicians and pathologists.
A woman with an abnormal cytology report needs to be further evaluated with colposcopy to confirm the presence of abnormalities, and colposcopy services are scarce in many resource-limited countries.
Screen-positive women have to make multiple visits for diagnostic confirmation and treatment.

VIA can overcome many of the disadvantages of cytology as listed above. The advantages of VIA are the following:

VIA does not require laboratory infrastructure.
VIA can be performed by various categories of health personnel (general practitioners, nurses, midwives, etc.) after a short period of training.
The consumables are affordable and readily available.
VIA is a truly point-of-care test, and the woman can immediately be informed of the test outcomes; the test-negative women can be reassured and advised.
Immediate availability of the results enables management of the test-positive women during the same visit.
The sensitivity of VIA is higher than or similar to that of cytology, especially in resource-limited settings.
Screening of women with VIA followed by appropriate management of screen-positive women can significantly reduce mortality from cervical cancer, as demonstrated in randomized controlled trials.

However, VIA has certain limitations as well.

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