Colposcopic examination of the vagina (vaginoscopy) is tedious and requires not only the usual application of Acetic acid, but also the manipulation of all walls and folds. Uneven surface of the vagina makes it difficult to detect all suspiciuos areas because the lesions may be hidden between the mucosal folds of the vagina.
Colposcopy of the vagina is complicated by several problems:
field to be examined is large and it is difficult to see most of the changes at a right angle
many of patients have already had hysterectomy, so it is not possible to view all the affected areas
preinvasive disease is often multifocal
because the treatment VAIN is complicated, it is even more important to differentiate viral disease from premalignant lesions
Vaginoscopy is performed after the 5% Acetic acid solution is applied to the whole vagina. Any excess liquid should be wiped, as Acetic acid gives a burning sensation in the vagina. The largest possible speculum should be used and its position frequently changed to allow inspection of all mucosal surfaces. All four walls of the vagina starting from vaults, down to the introitus should be examined. Speculum must be completely opened and rotated 360 degrees, especially if vaginal folds are prominent.
Unlike other parts of the lower genital system, application Lugol's solution is always necessary during vaginoscopy, in order to reduce the risk of missing abnormal fields.
Adequate/inadequate for the reason (i.e: inflammation, bleeding, scar)
Colposcopic examination of the vagina may be adequate or inadequate. Colposcopic examination is adequate if all vaginal walls can be visualized.
Inadequate colposcopy of the vagina is the one where the entire vaginal epithelium is not accessible. It is usually due to vaginal stenosis caused by neoplasia, previous surgery on the lower genital organs (vaginoplasty, scars) or irradiation, severe atrophia, pelvic tumors which externally compress the vaginal walls or congenital malformations (septum). Some dermatologic diseases such as Lichen planus may result in adhesions of the walls or even complete obliteration of upper vagina. Colposcopic examination is also inadequate if the vaginal walls are obscured by discharge or the blood. If colpsocopic examination is inadequate the reason of inadequacy should be described.
Transformation zone
Transformation zone (TZ) is the whole area between the original squamo-columnar junction and the active (new) squamo-columnar junction. In some cases, original squamo-columnar junction may be positioned in upper vagina, thus expanding transformation zone to vaginal vaults.
During the embryonic development, vagina becomes coated by squamous epithelium. In those periods of life when columnar epithelium everts to the ectocervix, this eversion can affect very large surface area and extend to the vaginal vaults. Transformation of glicogenated vaginal epithelium to keratinized non-glicogenized one is not common and is usually associated with chronic trauma of small degree as in the presence of a pessary or prolapse.
Sometimes there is a congenital variation of normal development of the epithelium of the vagina and remnants of columnar epithelium may spread from the cervix to the upper parts of the vagina, usually in the anteroposterior line. In these fields squamous metaplasia will take place, similar to what described in the cervix. This metaplasia creates congenital aceto-white changes and also a congenital transformation zone. It happens in only about 2.5% of women and this is why the process of metaplasia which is so often present in the epithelium of other parts of the female genital system, is rarely seen in the vagina.
