Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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Treatment of cervical intraepithelial neoplasia by loop electrosurgical excision procedure (LEEP) should follow the scheme outlined in Chapter 11. Management of women who have persistent disease at the follow-up visit(s) is discussed in the next section. Adverse effects, complications, and longterm sequelae of LEEP Most women experience some transitory pain from the injection of local anaesthetic into the cervix. Severe perioperative bleeding occurs after 2% or less of LEEP procedures. Women should be advised to contact the clinic if they have any concerns during the postoperative period. It is advisable to give written post-operative instructions that outline the following points. Few women complain of post-operative pain. If post-operative pain occurs, it usually is similar to cramps; women should be instructed to use oral analgesics such as acetaminophen or ibuprofen, if necessary. A blood-tinged, dark brown (from the Monsel’s paste) mucus discharge usually lasts for one or two weeks after treatment. Severe and moderate postoperative bleeding occurs in a few women, who should be seen promptly. Healing after LEEP usually takes place within a month. When post-operative bleeding occurs, it usually appears 4-6 days after treatment and often from the posterior lip of cervix. This bleeding can usually be controlled by fulguration, applying Monsel’s paste, or using a silver nitrate applicator stick. Rarely, placement of a suture at the bleeding site is necessary. The risk of post-operative infection is very small and can probably be reduced even more by delaying surgical treatment until any woman with a likely diagnosis of PID, cervicitis, vaginal trichomoniasis or bacterial vaginosis has been adequately treated and recovered. If a woman presents post-operatively with a malodorous discharge, it should be cultured if possible and empirical treatment prescribed with antibiotics that are effective for PID (see Table 11.1). In developing countries, it may be preferable to institute routine presumptive treatment with antibiotics after LEEP (doxycycline 100 mg orally, two times a day, for seven days and metronidazole 400 mg orally, three times a day, for seven days). The squamocolumnar junction is in the endocervical canal at the follow-up evaluation in approximately 2% of women. This presents a challenge for adequate colposcopic examination and cytological sampling. Women should be warned that cervical stenosis, partial or complete, is rarely encountered (probably less than 1%), but is more common in menopausal women. Management of women with persistent lesions at follow-up All women, regardless of whether or not the pathology report states that the excisional margins are clear, should be followed up at 9 - 12 months from treatment to evaluate regression or persistence of lesions and complications. Treatment failures (persistent lesion(s) at follow-up) are detected in less than 10% of women when they are checked at the follow-up appointment. It is advisable to biopsy all persistent lesions to rule out the presence of unsuspected invasive carcinoma. Persistent lesions should be re-treated with cryotherapy or LEEP or cold-knife conization, as appropriate. 111
Chapter 14 Decontamination, cleaning, high-level disinfection and sterilization of instruments used during the diagnosis and treatment of cervical neoplasia • Decontamination refers to steps taken to ensure that a medical instrument is safe for handling by reducing its contamination with microorganisms. This step results in the inactivation of hepatitis B virus and HIV. • Cleaning ensures the removal of biological material from the instruments. • The destruction of all micro-organisms, including bacterial spores on an instrument, is referred to as sterilization. • When sterilization equipment is not available, or the instrument cannot be sterilized, high-level disinfection (HLD) is used. HLD results in all forms of microbes, except bacterial spores, being destroyed. • Strict implementation of the above procedures according to a written manual is helpful in quality assurance of safe utilization of reusable instruments. The basic steps involved in the safe utilization of reusable instruments for colposcopy and treatment of cervical intraepithelial neoplasia (CIN) are summarized in this chapter. A thorough knowledge and understanding of the steps in the high-level disinfection (HLD)/sterilization process is absolutely essential, as it ensures that the instruments used are free of infectious agents. Any lack of compliance with this process can lead to contamination of the sterilized instruments and harm to the patient. The process for re-use of the instruments begins with decontamination and continues through cleaning, sterilization/HLD, storage and handling. A quality assurance programme will help to ensure that instruments are processed adequately for re-use. There are three basic steps before instruments, used for clinical and surgical procedures, can be reused: decontamination, cleaning and sterilization/HLD. These are briefly discussed and the methods used for sterilizing different instruments are described. Decontamination Decontamination comprises a series of steps to make a medical instrument or device safe for handling by reducing its contamination with microorganisms or other harmful substances. Usually, these procedures are performed by the nursing, technical or cleaning staff, and decontamination protects these workers from inadvertent infection. If these procedures are carried out properly, decontamination of the instruments will be assured before handling for cleaning. This step results in the inactivation of most organisms such as hepatitis B and HIV. Further processing is necessary to ensure that the object is cleaned and then sterilized. Cleaning Cleaning is a crucial step in providing safe, infectionfree instruments. Vigorous manual cleaning with running water and liquid soap or detergent removes biological material such as blood, body fluids and tissue remnants. Instruments should be cleaned as soon as possible after use. If biological material is left behind, it can act as a sanctuary for residual microorganisms, protecting them from the effects of disinfection and sterilization. 113
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Colposcopy and Treatment of Cervica
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INTERNATIONAL AGENCY FOR RESEARCH O
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Published by the International Agen
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Contents 11 Management that provide
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Acknowledgements The authors gratef
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Preface Health care providers have
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Chapter 1 An introduction to the an
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An introduction to the anatomy of t
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Chapter 2 An introduction to cervic
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An introduction to cervical intraep
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Chapter 3 An introduction to invasi
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An introduction to invasive cancer
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Chapter 4 Table 4.1: Indications fo
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Chapter 4 FIGURE 4.2: Colposcope wi
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Chapter 4 FIGURE 4.6: Endocervical
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Chapter 4 Table 4.2: Preneoplastic
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Chapter 5 between the two ocular le
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Chapter 5 Obtain specimens for labo
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Chapter 5 FIGURE 5.2: Biopsy techni
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Chapter 5 tissue tends to mimic inv
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Chapter 6 invasive carcinoma. Even
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Chapter 6 ages (Figures 1.7d, 1.7e,
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Chapter 6 FIGURE 6.7: The colour ch
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Chapter 6 Crypt openings Immature s
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Chapter 6 a FIGURE 6.17: An area of
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Chapter 7 The colposcopic diagnosis
Page 69 and 70: Chapter 7 appears as individual sma
Page 71 and 72: Chapter 7 acid stain is correlated
Page 73 and 74: Chapter 7 FIGURE 7.15: Moderately d
Page 75 and 76: Chapter 7 FIGURE 7.23: A dense acet
Page 77 and 78: Chapter 7 FIGURE 7.30: Mustard yell
Page 79 and 80: Chapter 7 We recommend that the stu
Page 81 and 82: Chapter 8 highlights this responsib
Page 83 and 84: Chapter 8 Appearance before applica
Page 85 and 86: Chapter 8 diagnosis of AIS and aden
Page 87 and 88: Chapter 8 a ↑ FIGURE 8.10: Adenoc
Page 89 and 90: Chapter 9 Inflammatory lesions of t
Page 91 and 92: Inflammatory lesions of the uterine
Page 93 and 94: Inflammatory lesions of the uterine
Page 95 and 96: Chapter 10 Table 10.1: Common sourc
Page 97 and 98: Chapter 10 Table 10.2 (cont.): A su
Page 99 and 100: Chapter 11 FIGURE 11.1: Flow chart
Page 101 and 102: Chapter 11 treatment policies for p
Page 103 and 104: Chapter 11 Vaginal delivery can be
Page 105 and 106: Chapter 12 involvement increases wi
Page 107 and 108: Chapter 12 Table 12.1: Eligibility
Page 109 and 110: Chapter 12 a b c d e f FIGURE 12.6:
Page 111 and 112: Chapter 12 during the follow-up in
Page 113 and 114: Chapter 13 (2) (1) FIGURE 13.2: Ele
Page 115 and 116: Chapter 13 (1) (2) (3) (4) (5) (8)
Page 117 and 118: Chapter 13 Once the specimen has be
Page 119: Chapter 13 in the endocervical cana
Page 123 and 124: Decontamination, cleaning, high-lev
Page 125 and 126: References Herrero, R. (1997) Preva
Page 127 and 128: Further reading Suggestions on furt
Page 129 and 130: Appendix Leukoplakia Condylom
Page 131 and 132: Appendix regardless of your pregnan
Page 133 and 134: Appendix Monsel’s paste Ingredien
Page 135 and 136: Appendix 5 The modified Reid colpos
Page 137 and 138: Index Acetowhitening . . . . . . .
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Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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