Gynaecological examinations in Florence

• The examination begins with the direct exploration of the external genitals.

• A vaginal speculum is chosen based on the woman's parity and inserted without any prior vaginal exploration.

• An initial direct observation is made with the colposcope to assess general characteristics, shape, size, any cervical lacerations, characteristics of the vaginal fornices, cervical mucus, and vaginal contents.

• Direct colposcopic examination is useful for observing the blood capillary network with a green filter, preferably after cleansing the cervix with saline solution.

• The fourth step involves a second colposcopic observation after cleansing the cervix and vaginal fornices with a 5% acetic acid aqueous solution.

• After this observation, a targeted biopsy of the suspicious lesion is performed under colposcopic guidance.

• The Schiller's test with Lugol's solution constitutes the final stage of the colposcopic examination.

• Removal of the speculum.

• Vulvoscopy is performed. Initially, a direct observation is made, then the vulva is moistened with a 5% acetic acid aqueous solution for an extended period (1/2 minutes), especially at the inner surface of the labia minora and vaginal introitus.

1. Medical history

2. Clinical assessment of the external genitals

3. Introduction of the vaginal speculum

4. Sample collection for bacteriological examination

5. Endocervical sampling with a Cytobrush or cotton swab

6. Exocervical sampling using an Ayre spatula

7. First colposcopic observation with a saline solution, and after physiological solution

8. Second colposcopic observation, after application of a 5% acetic acid aqueous solution

9. Possible targeted exocervical and/or endocervical biopsy

10. Schiller's test and third colposcopic observation

11. Vaginoscopy with acetic acid and Schiller's test

12. Possible targeted vaginal biopsy

13. Vulvoscopy and perineoscopy

14. Possible targeted vulval and/or perineal biopsy

The colposcopic examination is essential for detecting alterations not visible to the naked eye in the lower genital tract. It is a painless exploration, at different magnifications, conducted before and after the application of specific reagents, of the entire lower genital tract, namely cervical colposcopy and fornices, vaginal colposcopy, vulvoscopy, and perineoscopy. During the colposcopy procedure, it is possible to identify lesions that require further histological investigations. Therefore, it is essential to take a tissue sample with biopsy forceps and send it to the laboratory. Histological analysis can be valuable for diagnosing benign or malignant tumours that may affect the uterine cervix. Colposcopy with biopsy is recommended for all women with abnormal Pap test results and for those experiencing suspicious symptoms of cervical neoplasia. This procedure is not recommended for pregnant women and should be carefully considered during menstruation. Specific preparation for colposcopy with biopsy is not required, it does not involve the use of anaesthesia, and it is generally free of adverse side effects. The result of colposcopy with biopsy is considered negative if the analysed cell sample shows no significant abnormalities. Conversely, it is considered positive if the cells analysed in the sample exhibit neoplastic characteristics, both benign and malignant.

The increasing interest in the use of CO2 laser has encouraged, in recent years, research on accessory instrumentation until the coupling of the laser arm to a microscope or colposcope was devised. The laser beam control system was carried out using a micromanipulator. It consists of a metal ring and a mirror that reflects the laser beam, manoeuvrable via joystick. This system allows directing the laser beam under direct colposcopic control. The beam can also be more or less focused, depending on the surgeon's needs, using a mechanical system located at the joint arm screw. This system can be adapted to any type of colposcope or microscope. The use of the more or less focused laser beam has paved the way for a new type of minimally invasive surgery that has allowed, over time, to make all interventions on lower genital tract pathologies ambulatory procedures with or without the use of local anaesthetics.

The main pathologies in which the technique of operative colposcopy is employed are:

• Conisations

• Remodelling of OUE in case of infertility due to cervical cause

• Vestibulectomy

• Resection of vaginal septa

• Drainage and cauterisation of vaginal cysts

• Excision of suspicious lesions in the vulvar area

• Enlargement of the vaginal orifice in case of strictures (post-inflammatory or postpartum)

• Treatment of Bartholin's gland cysts

• Treatment of condylomas in any area of the lower genital tract

• Excision of hamartomas at any level, both vulvar and inguinal.