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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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Preventing errors in VIA Ė Inadequate visualization of the transformation zone


In certain circumstances the SCJ may not be fully visualized, and as a result the assessment of the transformation zone (TZ) may be incomplete. This is an inherent limitation of VIA, due to which small lesions inside the endocervix may be missed, especially in postmenopausal women. However, efforts must be made to visualize the SCJ as much as possible. The TZ may be inadequately visualized in the following circumstances.

  • The SCJ is located partially or completely inside the endocervical canal: An SCJ that is well within the endocervical canal cannot be visualized during VIA examination. Sometimes the SCJ may be partially inside the endocervical canal and can be visualized after gentle manipulations. The unseen part of the SCJ may be visualized by opening the speculum blades wider, taking care not to cause discomfort to the woman. If the SCJ is still not completely visible, applying gentle pressure on the outer aspect of the ectocervix or to the vaginal fornices with cotton swabs moistened with 5% acetic acid may evert the cervical lips and make the SCJ visible.

  • Presence of mucus, discharge, or blood: Thick cervical mucus during the luteal phase of the menstrual cycle may hinder visualization of the SCJ. The mucus is tenacious and difficult to remove. In such situations, visualization of the SCJ can be made possible by pushing the mucus to the side or by gently pushing it inside the endocervical canal with the help of a small cotton swab moistened with 5% acetic acid. Care should be taken not to induce bleeding from the columnar epithelium.
    Excessive discharge or blood (e.g. in menstruation, cervicitis) obscuring the view of the cervix should be gently removed with the help of cotton swabs moistened with 5% acetic acid.

Use of a dry cotton swab at any point during the VIA procedure is discouraged, because it can injure the fragile columnar epithelium and induce bleeding.

  • Presence of polyps or nabothian cysts close to the SCJ: Polyps located near the SCJ may interfere with complete visualization of the TZ. Mucous polyps are usually mobile and can be manipulated with the help of moist cotton swabs to visualize the cervix.

Large nabothian cysts located near the SCJ can obstruct the full 360į view of the SCJ. Using a moist cotton swab to apply gentle pressure on the cervical lips on the outer aspect of the ectocervix in the same direction as the location of the nabothian cysts often enables the SCJ to be visualized.

The presence of large polyps (pedunculated or sessile) or nabothian cysts can make visualization of the SCJ difficult, and the SCJ may not be visible even after manipulation.


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