Vaginoscopy

INTRODUCTION — Vaginoscopy refers to use of an instrument, other than a speculum, to visualize the vaginal canal. It is used most often for examination of children. The clinician should choose an instrument that will not damage the hymen or lower genital tract of the unestrogenized child. The anatomic integrity of the child's hymenal tissue is important from a cultural and forensic point of view: families often need to be assured that vaginoscopy maintains the child's sexual abstinence; anatomic disruptions of the hymenal tissues are used as forensic evidence of childhood sexual abuse.

PREPROCEDURE ISSUES — Informed consent for vaginoscopy should also include: removal of a foreign object, biopsy of abnormal-appearing findings, rectovaginal examination, and possible needle drainage (if a cyst is found). Prior to insertion of any instrument into the vaginal introitus, the anatomic features of the hymen should be documented and the amount of estrogen effect on the child's tissues should be assessed. (See "The pediatric physical examination: The perineum", section on 'Female genitourinary system' and "Gynecologic examination of the newborn and child", section on 'Evaluation of the hymen'.)

Hymenal tissue with a high estrogen effect (newborns and peripubertal children) is better able to tolerate iatrogenic stretch without tearing than tissue with a very low estrogen effect (children three to eight years of age) [1]. A pediatric vaginal speculum should not be used in routine examination of the prepubertal child's vagina because there is a risk of traumatizing the hymen and vaginal walls, even if the child is under general anesthesia.

Vaginoscopy with an irrigating endoscope can be performed in the office or as an examination under anesthesia. The site is determined by the child's ability to comply with instructions. Topical anesthetic is applied to the vulva approximately five minutes before inserting the vaginoscope [1]; the author uses a 2 percent preparation of viscous lidocaine. The author is more comfortable using a flexible irrigating endoscope for office procedures due to concern about inadvertent patient movement that might result in accidental injury. Patient compliance can be improved when they are informed that they will be able to see what the doctor sees inside their body. A flexible scope can be bent toward patients so they can visualize their lower genital tract or a video attachment with a monitor can be used.

INSTRUMENTATION — Historically, a popular technique for examination of a child's vagina involved the Cameron-Myers vaginoscope, which has interchangeable distal tubular structures of 0.7, 1.0, and 1.3 cm diameters (picture 1) [2,3]. This instrument was a modification of a veterinary otoscope [4,5]. The Killian nasal speculum has also been used for pediatric vaginoscopy [6]. Use of these instruments allows detection of large lesions and those that are a different color than the vaginal walls. However, if the lesion is accompanied by copious mucus or debris or is very small, detecting it with these instruments is difficult.

Vaginoscopy with an irrigating endoscope is ideal for examination of the lower reproductive tract of a prepubertal female patient (figure 1) [7-9]. The small diameter of the endoscope causes no distortion of the hymenal tissues and the irrigation fluid will not only lavage the vagina, but distend it sufficiently to allow good visualization of the cervix and vaginal canal. Lavaging the vagina of mucus and debris is important for detection of extremely small exophytic lesions that can be camouflaged. In addition, a small exophytic lesion will flap freely in the irrigating fluid, aiding in its detection.

Distension of the vaginal canal by fluid allows the cervix and the vagina to be visualized together. Use of an instrument other than an irrigating vaginoscope will not allow this panoramic view, since the Cameron-Myers vaginoscope or veterinary otoscope will only visualize what is directly adjacent to the distal portal of the scope. The general panoramic view of the cervix and vagina helps the examiner to appreciate any anatomic asymmetries suggestive of congenital anomalies, such as ectopic ureters (picture 2 and image 1) and müllerian defects. (See "Congenital anomalies of the hymen and vagina".)

Any endoscope with irrigating properties can be used. A bronchoscope or urethroscope is ideal because of the short length; however, a laparoscope, cystoscope, nephroscope, or hysteroscope can also be used (picture 3). Hysteroscopes, which have very small diameters, are necessary in some children. This can be a problem because the amount of fluid pressure distending the vaginal canal is lower as the scope diameter becomes smaller. An assistant placing pressure on the irrigating fluid bag or supplementing the pressure of the fluid with an attached large-volume syringe of fluid usually can overcome this problem. Bladder irrigating fluid or normal saline can be used as the distending fluid. High molecular weight fluids, as used in hysteroscopy, offer no advantage and are a deterrent to getting a good seal of the vulvar tissues around the endoscope due to their slippery consistency.

FINDINGS — Because of the fragility of the prepubertal vaginal epithelium, one will invariably notice pink discoloration on the final swab(s) of a series of swabs used to obtain cultures from the unestrogenized prepubertal vagina. On vaginoscopy, small petechiae will be noted on the cervix or vaginal side walls. This occurs so frequently that it should be considered normal in this situation (figure 2).

Rugation of the vaginal walls is variable, but usually low to minimal. Much of the prepubertal side walls are smooth and free of rugae.

Extensive papillary projections can be observed around embedded foreign objects. Lesser papillary projections are observed at the site of non-embedded foreign objects. It seems very likely that a foreign object could be expelled with Valsalva's maneuver before its discovery by vaginoscopy. Therefore, the physician should look for sites of papillary excrescences as possible evidence of a recently expelled foreign object when performing vaginoscopy for unexplained vaginal bleeding or discharge [10].

The unestrogenized vaginal walls will also frequently respond to trauma by forming granulation tissue. The mounds of friable tissue look bizarre under the magnification of vaginoscopy. This granulation tissue will resolve in most cases after application of topical estrogen cream to the vulva [11].

If an irrigating vaginoscope is not used, linear lacerations noted with a pediatric speculum would have to be attributed to the trauma of the speculum examination itself. This is detrimental if the examination is being performed to document sexual abuse. Therefore, speculums should never be used for evaluation of genital symptoms in a prepubertal female patient since abuse is always in the differential. By comparison, the vagina is lavaged during vaginoscopy, thus allowing good definition of acute trauma. However, there will be no vaginal distension if there has been avulsion of the vaginal apex, since the fluid will flow into the abdominal cavity.

In most cases without distinct pathology, the vaginoscopy will encounter a smooth or nodular symmetric cervix and smooth or slightly rugated symmetric vaginal canal. Suspicion of a urogenital anomaly must be raised when asymmetry of the cervix or vagina is noted or there are extra craters, dimples, or folds of tissue in the upper vagina.

Vaginoscopy with an irrigating endoscope has led to such a superior panoramic view of the prepubertal vagina and cervix that future clinical studies are warranted to better define and outline management for cervical and vaginal variants.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Vulvar cancer and vaginal cancer".)

SUMMARY

●Overview – Vaginoscopy refers to use of an instrument, other than a speculum, to visualize the vaginal canal. It is used most often for examination of children. (See 'Introduction' above.)

●Preprocedure issues

•Informed consent for vaginoscopy should also include: removal of a foreign object, biopsy of abnormal-appearing findings, rectovaginal examination, and possible needle drainage (if a cyst is found). (See 'Preprocedure issues' above.)

•A pediatric vaginal speculum should not be used in routine examination of the prepubertal child's vagina because there is a risk of traumatizing the hymen and vaginal walls, even if the child is under general anesthesia. (See 'Preprocedure issues' above.)

•Vaginoscopy with an irrigating endoscope can be performed in the office or as an examination under anesthesia. The site is determined by the child's ability to comply with instructions. Topical anesthetic is typically applied to the vulva approximately five minutes before inserting the vaginoscope. (See 'Preprocedure issues' above.)

●Instrumentation

•Vaginoscopy with an irrigating endoscope is useful for examination of children (picture 1 and figure 1). The small diameter of the endoscope causes no distortion of the hymenal tissues and the irrigation fluid will not only lavage the vagina, but distend it sufficiently to allow good visualization of the cervix and vaginal canal. (See 'Instrumentation' above.)

●Findings

•Small petechiae will be noted on the cervix or vaginal side walls. This occurs so frequently that it should be considered normal in this situation (figure 2). Rugation of the vaginal walls is variable, but usually low to minimal. Much of the prepubertal side walls are smooth and free of rugae. (See 'Findings' above.)

•Extensive papillary projections can be observed around embedded foreign objects. A urogenital anomaly should be suspected when asymmetry of the cervix or vagina is noted or there are extra craters, dimples, or folds of tissue in the upper vagina (picture 2). (See 'Findings' above.)