Electrosurgical loop excision of the cervical transformation zone: preclinical training proficiency.

INTRODUCTION: The purpose of this investigation was to evaluate learning errors and preclinical psychomotor skill acquisition among physicians learning the electrosurgical loop excision of the cervical transformation zone (ELECTZ) procedure. METHODS: Gynecologists attending one-day ELECTZ continuing medical education courses demonstrated their newly acquired ELECTZ cognitive and procedural skills. A bovine cervical model was used to simulate the uterine cervix and cervical pathology. Subjects performed successive procedures until an adequate specimen was obtained. RESULTS: The mean number of procedural attempts to achieve proficiency was 1.61; 38 of 51 (75%) subjects were proficient following three trials. Thirty-nine percent (20 of 51) of subjects were successful following the first attempt, and an additional 14 of 23 were successful after the second trial. The most common (27%) defective specimen shape resulted from rapid terminal excision and subsequent shallow skewed tissue. Temporary loop electrode or tissue impedance was experienced by 35% of subjects during the first procedure. CONCLUSIONS: The ELECTZ procedure is mastered by most physicians with few complications following a minimal number of attempts. The most common procedural errors resulted from excessively rapid surgical technique. Realistic management scenarios with simulated model practice should be used when teaching the ELECTZ procedure to physicians.

Colposcopy and cervical biopsy educational training models.

BACKGROUND: Realistic simulation models serve meaningful educational purposes. The intent of this article is to review the physical and educational features of three instructional colposcopy models, and to discuss the advantages and implications of the use of models in teaching colposcopic skills. METHODS: Models made from latex, steak, and the bovine cervix were assessed as instructional devices to simulate the uterine cervix and cervical disease. Model construction, preparation, and unique features were critiqued. The models were also evaluated for their potential use in the preclinical teaching of important colposcopic skills. RESULTS: The latex model required minimal assembly but was costly. It was limited in design, which would exclude the training of most colposcopic techniques. The steak model used readily available materials, facilitated colposcopic skill acquisition, and was the least expensive model. The bovine model best simulated human cervical tissue, was intermediate in cost, and enabled teaching a variety of colposcopic procedures. The optional silicone inserts realistically demonstrated the spectrum of cervical disease. CONCLUSIONS: Various cervical biopsy models have different strengths and weaknesses for teaching colposcopic procedural skills. Available models each possess unique features designed to reproduce anatomy, pathology, tissue texture, and technical spatial limitations. The models permit assessment of gynecologic knowledge and psychomotor abilities.

Noninvasive detection of Chlamydia trachomatis in men: a comparison of two immunoassay tests.

This investigation compared a rapid enzyme immunoassay test and an enzyme-amplified immunoassay test with culture for the noninvasive detection of Chlamydia trachomatis urethritis in men. Urine specimens from 108 male subjects were evaluated for the presence of C trachomatis antigen, using the Kodak Surecell Chlamydia rapid enzyme immunoassay test and IDEIA Chlamydia enzyme-amplified immunoassay test. The test results were then compared with urethral C trachomatis culture and urethral Gram's stain analyses. Performance characteristics of the two tests were similar. The rapid chlamydial enzyme immunoassay test demonstrated several clinical advantages. Appropriate use of these tests may decrease patient morbidity and clarify organism etiology for enhanced specific medical care of urethritis in men.

Office procedures. Colposcopy.

Colposcopy is a clinical procedure to examine the epithelium of the uterine cervix and surrounding anogenital area with a magnifying instrument to detect the presence of cervical neoplasia and to identify abnormal tissue for biopsy. The procedure is enhanced by the use of chemical solutions that assist discrimination of normal tissue and abnormal lesions. Colposcopic examination and directed biopsy of the most severe focus of cervical neoplasia ensure a valid representation of the status of cervical disease. The results from the cytologic smear, histologic evaluation, and colposcopic impression collectively determine appropriate patient management.

Lethal tissue temperature during cervical cryotherapy with a small flat cryoprobe.

BACKGROUND: Some female patients, especially those with cervical intraepithelial neoplasia III (CIN III), are not successfully cured following cervical cryotherapy, for which a small flat cryoprobe tip is commonly used. The thermodynamic effect produced in the cervical tissue by this device has not been previously described. This study examined the capability of a small flat cryoprobe tip to generate a lethal temperature during thermocouple-monitored cryosurgery of the cervix. METHODS: A thermocouple was placed in the cervix 5 mm from the cryoprobe margin, and a pyrometer indicated temperatures generated by nitrous oxide cryosurgery. Iceball lateral spread of freeze was measured with a cryosurgical iceball gauge. RESULTS: A minimum temperature of -2C degrees was generated at the termination of freeze (6 1/2 minutes). The maximum lateral spread of freeze at termination was 6.2 mm. A lethal zone of 4.2 mm was estimated based on a 2-mm recovery zone. CONCLUSIONS: When compared with morphometric studies of cervical dysplasia depth of involvement, an estimated 12.5% of CIN III would be inadequately treated based on our in vivo data. A small flat cryoprobe is incapable of eradicating all severe premalignant cervical disease deep within the glandular clefts. An alternative treatment method, such as electrosurgical loop excision of the cervical transformation zone (ELECTZ), therefore, may be the preferred treatment modality for CIN III:

Cervical carcinoma in situ undetected by Papanicolaou smear but identified by cervicography. A case report.

The following case report demonstrates the clinical use of cervicography as an adjunct test to identify premalignant or malignant cervical disease. An asymptomatic woman seeking routine health maintenance care was screened by serial Papanicolaou (Pap) smears and cervicography. The interval Pap smears were interpreted as satisfactory and within normal limits; however, the cervigrams were interpreted sequentially as atypical and positive. A subsequent cervical biopsy revealed carcinoma in situ. Cervicography, as an adjunct test, enhanced cervical cytologic screening of a woman considered to be at high risk because of a prior history of genital human papillomavirus infection.

A comparison of three rapid chlamydial tests in pregnant and nonpregnant women.

BACKGROUND: The purpose of this investigation was to evaluate the performance characteristics of three rapid immunoassay tests to detect Chlamydia trachomatis cervicitis. METHODS: Endocervical samples from 506 women were evaluated using the three rapid immunoassay tests and the results were compared with those obtained by an endocervical chlamydial culture. RESULTS: The prevalence of C trachomatis cervicitis was 9.3%. Overall sensitivity and specificity of the Abbott TestPack Chlamydia test were 66.0% and 99.8%, respectively, of the Kodak Surecell Chlamydia test were 85.1% and 99.3%, respectively, and of the Unipath Clearview Chlamydia test were 85.1% and 98.5%, respectively. Pregnancy did not affect test specificity, but did influence sensitivity. The tests ranged from 5% to 22% less sensitive in nonpregnant women. CONCLUSIONS: The results of the investigation establish that the Clearview and Surecell chlamydial immunoassay tests performed well, particularly for pregnant women.

Colposcopic accuracy in a residency training program: defining competency and proficiency.

BACKGROUND: The determination of proficiency in procedural skills has evoked keen interest, but meaningful guidelines are limited by the absence of pertinent clinical data. Colposcopic accuracy is defined as the clinical correlation between a colposcopic impression and a histologic report. The colposcopic accuracy of physicians in a university-based family practice residency colposcopy program was evaluated. METHODS: Demographic information, clinical findings, and laboratory results of patients evaluated by colposcopy were prospectively recorded. Colposcopic accuracy was calculated based on the agreement of the colposcopic impression with the histologic interpretation within one histologic grade. RESULTS: Colposcopic examinations were performed on 282 patients. Histologic evidence of premalignant cervical disease was identified in 115 patients as follows: mild dysplasia, 72; moderate dysplasia, 24; and severe dysplasia, 19. The colposcopic impression agreed within one histologic grade in 188 of 205 patients for a colposcopic accuracy rate of 91.7% (95% CI = 87.1% to 95.1%). CONCLUSIONS: Given an acceptable latitude of clinical correlation between the colposcopic impression and histologic interpretation, the colposcopic accuracy of family physicians compared favorably with that reported by other colposcopists. The more common colposcopic errors were overestimation of low-grade disease and underestimation of high-grade disease. Colposcopic accuracy at an essential minimal proficiency level of 80% should form the basis for assessing specialized perceptual ability and therefore determining colposcopic competency.

Cryosurgical equipment: a critical review.

BACKGROUND: Cryosurgery is frequently used by family physicians to treat benign and premalignant epithelial disease. A professional medical team consisting of a practicing cryotherapist and a mechanical engineer independently critically evaluated the design, function, and performance of selected cryosurgical equipment. METHODS: Qualitative observations and quantitative measurements were performed on seven nitrous oxide cryosurgical units and one liquid nitrogen unit, representing seven manufacturers and distributors. Specific isotherm generation distributions, lateral spread of freeze and refreeze measurements, defrost intervals, recovery zone sizes, relative ease of use, and component characteristics were comparatively assessed. RESULTS: The in vitro mean lateral spread of freeze distance at 180 seconds varied between 5.8 mm for the Frigitronics CryoPlus and 4.6 mm for the Leisegang LM-900. The mean -20 degrees C isotherm generation time, measured by a thermocouple 3 mm lateral to the cryoprobe tip margin, ranged from 229 seconds for the Wallach WA-1000B to 361 seconds for the Spembly PCG 9R. Defrost times varied between 2 seconds for the Wallach WA-1000B and 320 seconds for the Brymill Mini-Cryogun. Refreeze time was quickest (36 seconds) using the GyneTech GT-1S. The mean in vitro recovery zones varied between 1.6 mm and 2.1 mm. CONCLUSIONS: This evaluation documented both differences and similarities among various cryosurgical units in terms of design, function, and performance. The Wallach, Frigitronics, and GyneTech nitrous oxide cryosurgical units demonstrated the best overall performance.

Reid's Colposcopic Index.

Reid's Colposcopic Index (RCI) is a systematic, objective method of colposcopically grading the severity of premalignant cervical lesions. The index considers four colposcopic signs: lesion margin, color of acetowhitening, blood vessels, and iodine staining. The RCI can accurately predict the histologic grade of cervical disease, readily permitting differentiation between low-grade cervical disease and high-grade disease. Hence, use of the index helps direct the clinician to perform a biopsy of the most significant abnormal cervical lesions and enhances the formulation of the colposcopic impression.

Women's use of over-the-counter antifungal medications for gynecologic symptoms.

BACKGROUND: Over-the-counter (OTC) antifungal products for vulvovaginal candidiasis (VVC) have gained tremendous popularity, as evidenced by staggering increases in sales since the products were switched from prescription-only to OTC status. The rapid escalation in the sale of these products may imply that women are using them inappropriately. The purposes of this study were to determine (1) whether women could correctly diagnose VVC and common genitourinary tract problems after reading classic case scenarios, (2) whether women could correctly select the appropriate treatment for these cases, and (3) whether a previous diagnosis of VVC by a clinician had any effect on a woman's ability to self-diagnose and self-treat VVC. METHODS: Women 16 years of age and older were recruited from medical and community sites to complete a 63-question survey instrument designed to assess their knowledge of the symptoms and signs of pelvic inflammatory disease, bacterial vaginosis, acute cystitis, vaginal trichomoniasis, and vulvovaginal candidiasis after reading classic case scenarios. RESULTS: A total of 601 women completed the questionnaire, 552 subjects and 49 medically trained women who served as a criterion standard for comparison. Of the 552 subjects, 365 reported a prior diagnosis of VCC and 154 reported no such prior diagnosis. The medically trained cohort was more accurate in diagnosing VVC (83.7% correct) than were subjects who had received a prior diagnosis of VVC (34.5% correct), and more accurate than subjects without a previous diagnosis of VVC (11.0% correct, P < .001). A greater percentage of subjects in whom VVC had been previously diagnosed, as compared with the medically trained cohort, would use OTC agents inappropriately for pelvic inflammatory disease (6.7% vs 4.3%, respectively; P = NS), bacterial vaginosis (14.6% vs 6.4%, respectively; P = .028), urinary tract infection (2.0% vs 0%, respectively; P < .001), and vaginal trichomoniasis (11.8% vs 6.6%, respectively; P = .048). CONCLUSIONS: A minority of women were able to correctly diagnose VVC from a classic case scenario. A prior clinical diagnosis of VVC had only a moderate positive effect on subjects' ability to correctly diagnose a classic case. Based on our findings, women likely use OTC antifungals inappropriately to treat gynecologic conditions that are similar but potentially more severe. Numerous adverse consequences may result from misdiagnosis. Improved patient education by health care providers and the manufacturers of OTC antifungal drugs might improve this diagnostic problem.

Cervicography: an intermediate triage test for the evaluation of cervical atypia.

BACKGROUND: A substantial number of abnormal Papanicolaou (Pap) smears are reported as demonstrating "cytologic atypia." This finding may actually represent premalignant cervical disease. Some of these patients may not be able to afford definitive colposcopic examinations, and simply repeating cytologic testing may result in missed treatable disease. The purpose of this study was to evaluate the use of cervicography as an intermediate triage test for women with atypical cervical cytology. METHODS: Women with a recent smear demonstrating cytologic atypia were evaluated using colposcopy, biopsy, and cervicography. RESULTS: Colposcopically directed cervical biopsies were obtained from 224 of 685 women with cytologic atypia. The histologic specimens confirmed evidence of cervical dysplasia for 166 women. Of these women, cervicography detected 74.7% of those who had mild dysplasia, 87.5% of those who had moderate dysplasia, 75% of those who had severe dysplasia, and the one patient who had cervical cancer. Most (93%) of the women with dysplasia that was undetected by cervicography had mild dysplasia. CONCLUSIONS: Cervicography may be an effective intermediate triage test for the evaluation of young women with Pap smears demonstrating cytologic atypia.

Vaginal intraepithelial neoplasia III detected after hysterectomy for benign conditions.

Because primary vaginal cancer is rare, many experts discourage routine cytologic sampling of the vaginal vault following hysterectomy for benign circumstances. The following report describes a case of vaginal intraepithelial neoplasia III (VAIN III) detected by a vaginal vault Papanicolaou smear obtained from an asymptomatic 57-year-old woman 23 years after she had a total abdominal hysterectomy for a benign condition. As VAIN III is a true vaginal cancer precursor, the innocent disregard of recommended screening practices averted significant morbidity and possibility mortality for this otherwise healthy woman.

Naked-eye inspection of the cervix after acetic acid application may improve the predictive value of negative cytologic screening.

BACKGROUND: The purpose of this study was to assess the predictive value of naked-eye inspection of the cervix (NIC) after acetic acid application as an adjunct to Papanicolaou (Pap) testing for cervical cancer screening. METHODS: Study subjects were women attending a medical college student health clinic either for cervical cytologic screening (67%) or because of a recent atypical cytologic screening result (33%). All study participants received cytologic screening, cervicography, and NIC. RESULTS: Of the 95 patients, 71 (75%) had abnormal findings on NIC. Fifty-one patients underwent colposcopy with biopsy, including 48 of the 71 with an abnormal finding on NIC. The results of 40 of the biopsies were abnormal: 36 showed human papillomavirus or low-grade squamous intraepithelial lesions, 3 showed high-grade squamous intraepithelial lesions, and 1 showed invasive cervical cancer. Sixty-five percent (26) of the abnormal biopsy findings occurred in women with normal cytologic test results. NIC and cervicography both were effective in identifying patients with abnormalities, but the combination of NIC followed by cervicography referred fewer women for colposcopy than did a positive result on NIC alone (52% vs 75%). The combination of a negative Pap smear and a negative NIC result had a 91% predictive value for the absence of cervical intraepithelial neoplasia. This was a significant improvement over cytologic screening alone. CONCLUSIONS: In this study, the combination of cytologic screening (Pap smear) and NIC increased the screening yield as compared with a Pap smear alone but with some loss of positive predictive value. NIC significantly improved the predictive value of negative cytologic screening results.

Colposcopes: a critical review.

A multidimensional professional team consisting of a practicing colposcopist, a mechanical engineer, and a medical photographer independently critically evaluated the features of selected colposcopes. Qualitative observations and quantitative measurements were performed on 13 colposcopes representing eight manufacturers and distributors. Optical characteristics, ocular system operation, mobility and stability, relative ease of use, component characteristics, space for instrumentation, and visual illumination, uniformity, and color were comparatively assessed. The specific colposcope information provided may benefit practicing physicians or novice colposcopists who are contemplating purchasing a colposcope. The presented framework of critical feature evaluation may also facilitate the informed selection of other colposcopes not included in this selective, critical, comprehensive review.

Colpophotography systems: a review.

Colpophotography and video colposcopy systems are useful for pathology documentation purposes, patient education, and colposcopy training. A wide variety of colposcopic visual media components are available to enhance routine colposcopy. Colpophotographic systems supplied by eight colposcope manufacturers were critically evaluated by a colposcopist and a medical photographer. Components were independently and objectively analyzed. Photographic examination considered color, illumination uniformity, and coverage of illumination at all possible colposcopic magnifications. Photographs were developed by a standardized technique. The investigation results clearly demonstrated variability between different colpophotographic systems. Quality colpophotography is dependent on certain colposcope features and potential modifications. Colpophotography and video colposcopy systems complement the standard colposcopic procedure.

The efficacy of liquid-based cervical cytology using direct-to-vial sample collection.

BACKGROUND: Previous studies of liquid-based cervical cytology (LBCC) have used a split sample collection technique that creates a potential negative bias for its evaluation. Thus, the full diagnostic potential of LBCC has not been established. The purpose of our study was to determine rates of specimen adequacy and cervical cytologic and histologically confirmed diagnoses obtained with a liquid-based Papanicolaou (Pap) test using a direct-to-vial sample collection technique and compare these results with those obtained using the conventional Pap test (CPT). METHODS: A total of 1004 nonpregnant women aged 18 years or older with an intact cervix had Pap tests collected with an Ayre spatula and cytobrush, and the sample was placed in a preservative solution. The specimens were processed as thin layer Pap tests according to the manufacturer's specifications. Another group of 2110 women with a similar patient profile had a CPT collected immediately preceding the initiation of the trial. The subjects in each group consisted of an equal percentage of women presenting for a routine Pap test or a colposcopy examination. We compared the distributions of diagnostic categories between the groups using a chi-square test. RESULTS: A significantly greater percentage of satisfactory Pap tests were obtained using LBCC (84.0%) compared with the CPT (60.5%, P < .001). Fewer satisfactory but limited by (SBLB, 14.8%) and unsatisfactory (1.2%) Pap tests were reported using LBCC compared with the CPT (35.7% and 3.8%, respectively, chi2 = 170.7, P < .001). A significantly greater percentage of low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL) Pap test results were reported using LBCC (7.4% and 3.7%, respectively) compared with the CPT (1.7% and 1.7%, respectively, chi2 = 74.4, P < .001). The predictive value of a positive LBCC test (93.9%) was similar to that for a positive CPT (87.8%) when compared with histology results. CONCLUSIONS: Compared with the CPT, LBCC detected a significantly greater percentage of satisfactory Pap tests and significantly reduced the number of unsatisfactory and SBLB tests. Four times the percentage of LSIL and twice the percentage of HSIL Pap test results were obtained using LBCC compared with the CPT. These findings demonstrate that LBCC significantly improves the adequacy of Pap tests and may increase the rate of detection of cervical neoplasia compared with the CPT.

Treatment of bacterial vaginosis: a comparison of oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream.

BACKGROUND: Treatment options for bacterial vaginosis are numerous. The purpose of this study was to compare the efficacy of oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream for the treatment of bacterial vaginosis using traditional clinical and laboratory methods, as well as a new DNA probe test. We also determined the percentage of patients receiving each treatment who developed posttreatment vaginal candidiasis, a potential complication of treating bacterial vaginosis. METHODS: One hundred one women in whom bacterial vaginosis was diagnosed by standard criteria were randomly assigned to receive: oral metronidazole 500 mg twice daily for 1 week, 0.75% metronidazole vaginal gel 5 g twice daily for 5 days, or 2% clindamycin vaginal cream 5 g once daily for 7 days. Women with coexisting vulvovaginal candidiasis or vaginal trichomoniasis were excluded. Tests of cure by vaginal saline wet prep and potassium hydroxide microscopic examinations, Gram's stain, pH and DNA probe tests for Gardnerella vaginalis and Candida species were scheduled 7 to 14 days following treatment. RESULTS: There were no statistically significant differences in cure rates for oral metronidazole (84.2%), metronidazole vaginal gel (75.0%), or clindamycin vaginal cream (86.2%) (chi 2 = 1.204, df = 2, P = .548) using traditional clinical and laboratory criteria. Cure rates were lower based on DNA testing, indicating that Gardnerella vaginalis may remain after a clinical cure. This would explain cases of recurrent disease. Posttreatment vulvovaginal candidiasis was experienced by 12.5% of subjects treated with oral metronidazole, 14.8% of subjects treated with clindamycin vaginal cream, and 30.4% of subjects treated with metronidazole vaginal gel (chi 2 = 2.607, df = 2, P = .272). CONCLUSIONS: Oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream achieved nearly equivalent cure rates for the treatment of bacterial vaginosis. Patients treated with these agents experienced similar rates of posttreatment vulvovaginal candidiasis, but those using the intravaginal products reported being more satisfied with the treatment.

A neglected lesbian health concern: cervical neoplasia.

Many health care providers believe that lesbian women do not need routine Papanicolaou smears. This erroneous assumption fails to recognize that the majority of lesbian women have had prior heterosexual relationships and thus may be at risk for developing cervical neoplasia. The following case report describes a lesbian woman who denied prior heterosexual intercourse but who developed cervical intraepithelial neoplasia grade 2 (CIN 2) associated with a high oncogenic risk human papillomavirus (HPV) type. Sexual contact with multiple lesbian partners who had previous heterosexual relationships likely explains her cervical disease.

'See and treat' electrosurgical loop excision of the cervical transformation zone.

BACKGROUND: "See and treat" electrosurgical loop excision of the cervical transformation zone (ELECTZ) is an excisional surgical procedure that enables simultaneous histologic diagnosis and treatment of premalignant cervical disease, thus eliminating the need for a preliminary cervical biopsy and an additional patient visit. Indications for the procedure include an abnormal cervical Papanicolaou (Pap) smear and a colposcopic impression of cervical intraepithelial neoplasia (CIN). The purpose of this study was to assess the "see and treat" ELECTZ procedure performed by family physicians. METHODS: Women who were scheduled for colposcopic evaluation because of an abnormal cervical cytology report were enrolled from the practices of three family physician colposcopists located at three sites. The "see and treat" ELECTZ procedure was performed on patients with both abnormal Pap smear results and abnormal colposcopic findings. Procedural complications were documented. Subjects were evaluated at follow-up examinations during the first postoperative year to determine therapeutic cure. RESULTS: "See and treat" ELECTZ was performed on 48 women. The histologic results from "see and treat" ELECTZ were normal for 36.1% of subjects. When subjects with a low-grade lesion on Pap smear were considered, 40.7% had normal loop histologic findings. Of women with a preoperative colposcopic impression of low-grade lesion, 54.2% had normal histologic results, and 12% of women with a high-grade colposcopic impression had normal histologic results (P<.001). When the colposcopic impression was reported as high-grade disease, 82% of loop specimens were reported as CIN 2 or 3. CONCLUSIONS: Selective use of "see and treat" ELECTZ may be appropriate only when practiced by experienced colposcopists who are able to reliably differentiate low-grade from high-grade disease by means of colposcopy, and if cytologic and colposcopic findings unequivocally indicate high-grade cervical disease.