This document discusses visual inspection techniques for cervical cancer screening in developing countries. It begins by explaining the limitations of Pap smear screening in developing countries due to infrastructure and resource constraints. It then describes visual inspection with acetic acid (VIA) and visual inspection with Lugol's iodine (VILI) as alternative screening methods that are simpler, cheaper, and do not require a laboratory. The document provides details on the procedures for VIA and VILI, including how to interpret the results. It finds that VIA and VILI have reasonable sensitivity and specificity for detecting precancerous lesions compared to Pap smears, making them effective screening tools for developing world contexts.

1. Visual Inspection of the cervix
Aboubakr Elnashar
Benha university Hospital
Aboubakr Elnashar

2. CIN
(%)
No
StudyUniversityYearAuthor
1.074458HospitalCairo1987Hammad et al
3.15453CommunitySuez canal2007Abd El All et al
3.125522HospitalAin Shams2004-
2010
Shalakany
(2012)
7.73600HospitalMinia2014Sanad et al
Prevalence of CIN in Egypt
(Elnashar, 2014)
invasive cx ca in Egypt:
0.04%
(AbdelAll et al, 2007)
Aboubakr Elnashar

3. Cervical cancer is a preventable disease
1. Characteristic natural course with a slow progression
through a premalignant stage.
2. Premalignant stage can be detected by noninvasive
means
(Pap smear, HPV DNA & VIA).
3. An effective treatment for the premalignant lesions
Aboubakr Elnashar

4. Screening in developing countries
Difference between developing & developed
countries
I. Higher incidence: 80%
II. Higher mortality: 90%
III. Different risk factors
IV. Poor financial, human & technical resources
V. Inadequate follow up
Screening as used in the developed world is
inappropriate in developing countries
Aboubakr Elnashar

5. Pap smear: limitations
1. Requires:
microscopes,
laboratory,
trained technicians,
pathologists,
transport of specimens,
reporting, and
supplies.
2. Immediate results are not possible: time consuming
3. Only 50% of abnormal findings (CIN and cancers)
are detected—relies on periodic re-scanning.
Sensitivity 60-70%
Aboubakr Elnashar

6. 4. Lesions may be missed if:
Not exfoliating.
There is a barrier to exfoliation.
Cells are not sampled properly from SCJ and TZ
Abnormal cells are not transferred to the slide.
Slide cannot be read effectively {obscured by blood or
pus}.
The technician misses the precancerous cells.
Aboubakr Elnashar

7.  In developing countries:
Not appropriate or adequate
Not practical as a nationall screening
method:
 In developed countries:
ongoing supervision
refresher training
continued supplies
Aboubakr Elnashar

8. Comparison of Screening Methods
1. Sensitivity and specificity
Method Sensitivity (%) Specificity (%)
Cytology 45-85 80-98
VIA 60-90 66-96
HPV DNA 65-95 70-96
NEJM Nov17,2005
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9. 2. Screening Costs
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10. Visual Inspection Techniques
1. Unaided Visual Inspection
2. Visual inspection with acetic acid (VIA)
3. Visual inspection with acetic acid and
magnification (VIAM)
4. Visual inspection with Lugol’s Iodine (VILI)
Aboubakr Elnashar

11. 1. Unaided Visual Inspection
Aboubakr Elnashar

12. Normal Smooth, pink
Clear mucoid secretion
Central hole-'external os‘: Nulliparours-round
Multiparous-slit or criciate
Cervix in postmenopausal women is atrophic
Abnormal
Clinical interpretation:
Can be;
Infection
Ectopy (erythroplasia)
Benign tumour
Hypertrophy
Redness or congestion
Irregular surface
Distortion
Simple erosions (do not bleed on touch)
Cervical polyps (with smooth surface)
Abnormal discharge: foul smelling, dirty/greenish, cheesy white,
blood stained
Nabothian follicles
Prolapsed uterus
Suspicious of
Malignancy
Erosion that bleeds on touch or friable
Growth, with an irregular surface or friable
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13. Normal cervix No medical intervention required. Call for
re-screening, if 35 years or above,
according to established policy.
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14. Abnormal
cervix
Take swab for culture and send to laboratory (if
facilities available). Refer the patient
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15. Suspicious of Malignancy
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16. Good for Clinical Down staging
Misses Precancerous lesions
Dx at stage III & IV: ↓from 85% to 55%
Dx at stage I & II: ↑ from 15% to 45%
60% of early disease could be identified
11% were false positive
Only 15 of pre-cancerous lesions could be detected
(Singh et al 1992)
Aboubakr Elnashar

17. 2. Visual inspection with acetic acid
(VIA)
Aboubakr Elnashar

18. Pathophysiological basis of VIA
 Application of 5% acetic:
1. Coagulates the proteins of the nucleus & cytoplasm
:makes the protein opaque & white.
2. Dehydrates the cells: cytoplasmic volume is
reduced & the reflection is increased.
 Duration:
Variable
Appears: after 20 sec &
Disappears: after 2 min.
Aboubakr Elnashar

19. Effects of a.a.:
1.on the mucous: It coagulates mucous which can
then easily removed (mucolytic).
2.on the mature glycogen-producing epithelium:
no effect
{a.a. does not penetrate below the outer one-third of
the epithelium. The cells have very small nuclei & a
large amount of glycogen (not protein)}
3.on the col. epi.:
swell & slightly opaque
particularly if the beginning signs of metaplasia are
present: makes its recognition easier.
Aboubakr Elnashar

20. 4.on the immature metaplastic epi.:
gray & filmy.
{very thin & have large nuclei}:
5.on dysplastic cells:
white and opaue
{contain large nuclei & large amounts of chromatin
(protein)}:
6.on gland openings of the TZ.:
better outlined.
Aboubakr Elnashar

21.  When to perform?
Anytime during the menstrual cycle
Not during menstruation
Not using intravaginal medication
During pregnancy, at a postpartum examination
Intended for ages 20 to 50
Aboubakr Elnashar

22.  Prior to application of acetic acid
1. Inspect the external genitalia:
papules, vesicles, ulcerations, condylomata,
discharge, redness, swelling, excoriation.
2. Inspect the cervix: unaided
 Normal
 Abnormal:
 Suspicious
3. Use a dry cotton swab to wipe away any discharge,
blood, or mucus from the cervix.
Aboubakr Elnashar

23. Procedure
1. Wash the cervix with a 3%–5% acetic acid
solution.
2. Carefully inspect the cervix, especially the TZ,
with the naked eye.
Aboubakr Elnashar

24. Categories
Category Clinical Findings
Negative No acetowhite lesions or
faint acetowhite lesions;
polyp,
cervicitis, inflammation,
Nabothian cysts.
Positive Sharp, distinct, well-defined,
dense (opaque/dull or oyster white) acetowhite with
or without raised margins touching SCJ;
leukoplakia and
warts.
Suspicious
for cancer
ulcerative, cauliflower-like growth or
ulcer; oozing and/or bleeding on touch.
Aboubakr Elnashar

25. Reporting of lesions
1. VIA negative
 No significant acetowhite lesions.
 The most challenging category in VIA
 Acetowhite:
1. Nabothian cysts and polyps
2. Faint line at SCJ
3. Away from SCJ
4. Streak like
5. Dotlike areas on the columnar epithelium
6. Diffuse with columnar epithelium staining
Aboubakr Elnashar

26. Aboubakr Elnashar

27.  Negative:
Acetowhite area far from SCJ and not touching it is
insignificant.
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28. VIA negative.
The mild acetowhite staining in a linear pattern at the
lower edge of SCJ and around the two glandular
crypt openings is the typical appearance of immature
metaplasia
Aboubakr Elnashar

29. VIA negative.
The button-like, acetowhite area with ill-defined
margins is due to a Nabothian cyst.
Other ill-defined acetowhite areas are due to
squamous metaplasia. Aboubakr Elnashar

30. Nabothian cysts appear as
spot or button-like areas
after the application of a a.
There is dot-like
acetowhitening in the
columnar epithelium in
the anterior lip.
The SCJ is fully visible.
Negative
Aboubakr Elnashar

31. Negative:
The cervix is unhealthy, inflamed with ulceration,
necrosis, bleeding and inflammatory exudate.
ill-defined, diffuse, pinkish-white acetowhitening with
indefinite margins blending with the rest of
epithelium (arrows). Aboubakr Elnashar

32. 2. VIA-Positive
 Acetowhite areas:
Sharp, distinct, well-defined,
dense (opaque/dull or oyster white),
with or without raised margins
close SCJ
 identify:
1. Extension
2. Intensity of whiteness
3. Borders and demarcations
4. Size
5. Location
Aboubakr Elnashar

33. Leukoplakia (hyperkeratosis)
well demarcated white area
(before the application of aa),
due to keratosis, visible to the
naked eye. Usually leukoplakia is idiopathic, but it
may also be caused by chronic foreign body irritation, HPV
infection, or squamous neoplasia.
Condylomata found on the
cervix, associated with HPV
types 6 and 11. Condylomata
are usually obvious to the
naked eye (before aa ).
Aboubakr Elnashar

34.  Positive
Acetowhite area adjacent to SCJ is significant.
Aboubakr Elnashar

35. VIA-positive
well-defined, opaque
acetowhite area, with regular
margins, in the anterior lip,
adjacent to SCJ, which is
fully visible.
satellite lesions in the lower lip.
well-defined, opaque acetowhite
area, with regular margins, in
the anterior lip, adjacent to
SCJ, which is fully visible.
ill-defined white area in the lower
lip. The lesion is extending into
cervical canal.Aboubakr Elnashar

36. 3. Suspicious for cancer
 Dull, opaque, dense acetowhite area,
with raised and rolled-out margins,
irregular surface and bleeding on
touch in the posterior lip.
The lesion is extending into the cervical
canal.
The bleeding obliterates acetowhitening.
 proliferative growth
with dense
acetowhitening and
bleeding
Aboubakr Elnashar

37. VIA Performance:
Sensitivity Specificity
Minimum 65% 64%
Maximum 96% 98%
Median 84% 82%
Source: Adapted from Gaffikin, 2003
Sensitivity Specificity
Minimum 37% 86%
Maximum 84% 100%
Median 51% 89%
Pap test performance:
Aboubakr Elnashar

38. Strengths of VIA:
 Simple, easy-to-learn, minimally dependent upon
infrastructure.
 Low start-up and sustaining costs. Requires only
acetic acid, a speculum, and a light source (flashlight).
 Can be performed by nurses and midwives.
 Results are available immediately.
 Requires only one visit.
 Accuracy is comparable to Pap smear.
 Can be followed by VILI.
Aboubakr Elnashar

39. Limitations:
 False-positives may overload the referral system:
unnecessary tt of women who are free of
precancerous lesions in a single-visit approach.
 Standard training and quality assurance measures
are required
 Less accurate among post-menopausal women.
 Rater dependent.
Aboubakr Elnashar

40. Management:
 VIA: Negative:
 follow-up after 3-5 years acc to the decided policy.
 VIA test: positive
 Offer to treat immediately. or
 Refer for colposcopy and biopsy and then offer tt if a
precancerous lesion is confirmed.
 VIA : suspicious for cancer:
Refer for colposcopy and biopsy and further
management
Aboubakr Elnashar

41. Visual Inspection with Acetic Acid
Using Magnification (VIAM)
Aboubakr Elnashar

42. Visual Inspection with Acetic Acid Using
Magnification (VIAM)
 visualization of cervix after application of aa using low
power magnification (2.5x to 4x)
Magnascope (4X)
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43. 4. Visual inspection with Lugol’s iodine (VILI)
Aboubakr Elnashar

44. Pathophysiological basis of VILI
Glycogen rich tissues:
mahogany brown or
black
Glycogen rich:
Squamous epithelium
Squamous metaplasia
(mature)
Glycogen poor tissues do
not take up iodine:
mustard-yellow or
saffron-color.
Glycogen poor:
Columnar epithelium
CIN
invasive cancer
Laukoplakia
(hyperkeratosis)
Condylomata
Lugol’s iodine is glycophillic
Aboubakr Elnashar

45. Procedure:
 Vaginal speculum exam
 Apply Lugol’s iodine solution to the cervix.
 Viewing the cervix with the naked eye to identify color
changes on the cervix.
 The 5% solution consists of 5% (wt/v) iodine and 10% (wt/v) potassium iodide(KI) mixed in distilled water and has a total iodine content of
126.5 mg/mL. Potassium iodide renders the elementary iodine soluble in water through the formation of the triiodide ion.
 It is not to be confused with tincture of iodine solutions, which consist of elemental iodine, and iodide salts dissolved in water and alcohol. Lugol's
solution contains no alcohol.
 Schiller iodine composition is same as lugol s iodine, latter been more concentrated
Aboubakr Elnashar

46. Procedure involving VIA and VILI
1. Soak a clean swab in 5% aa and apply to the
cervix liberally.
2. Wait 1 minute.
3. Focus on TZ.
4. Note any acetowhite lesions: location, extension,
intensity of whiteness, borders.
5. Soak a clean swab in Lugol’s iodine solution and
apply to cervix liberally
6. Note the uptake in the areas of concern noted after
acetic acid.
Aboubakr Elnashar

47. Categories for VILI test results:
Category Clinical Findings
Negative Squamous epithelium turns brown
columnar epithelium does not change
color; or
irregular, partial or non-iodine uptake
areas.
Positive Well-defined, bright yellow iodine non-
uptake areas touching SCJ or close to the
os if SCJ is not seen.
Suspicious
for cancer
ulcerative, cauliflower- like growth or
ulcer; oozing and/or bleeding on touch.
Aboubakr Elnashar

48. Reporting of lesions
VILI: test-negative
 The squamous epithelium turns
brown
 columnar epithelium does not
change color.
 scattered and irregular, partial
or non-iodine uptake areas
associated with immature
squamous metaplasia or
inflammation.
Aboubakr Elnashar

49.  VILI: test-positive
 Well-defined, bright yellow
iodine non-uptake areas
touching the SCJ
Aboubakr Elnashar

50. VILI: Suspicious for cancer
 Clinically visible
ulcerative, cauliflower-
like growth or ulcer;
oozing and/or bleeding
on touch.
Aboubakr Elnashar

51. Test performance:
(Sankaranarayanan et al., 2008).
SpecificitySensitivity
85.576.8VIA
85.491.7VILI
Aboubakr Elnashar

52.  Strengths of VILI:
 Simple, easy-to-learn that is minimally dependent
upon infrastructure.
 Low start-up and sustaining costs. Requires only
Lugol’s iodine in addition to the equipment for VIA.
 Can be performed by nurses and midwives.
 Test results are available immediately: Decreased
loss to follow-up.
 High sensitivity results in a low proportion of
false negatives.
 VILI appears to offer improved accuracy and
reproducibility over use of VIA alone.
Aboubakr Elnashar

53. Limitations of VILI:
 Moderate specificity may result in over-referral and
over-treatment in a single-visit approach.
 Less accurate when used in post-menopausal
 standard training and quality assurance measures
are required
 Rater dependent.
 Lugol’s solution stains underwear and other objects
but is washable..
 Lugol’s iodine is more expensive than acetic acid,
but less is needed for the test.
Aboubakr Elnashar

54.  Management options
 VIA: Negative:
 follow-up after 3-5 years acc to the decided policy.
 VILI: positive:
 Offer to treat immediately, (without colposcopy or biopsy,
known as the “test-and-treat” or “single-visit” approach).
 Refer for colposcopy and biopsy and then offer treatment
if a precancerous lesion is confirmed.
 VILI: suspicious for cancer:
 Refer for colposcopy and biopsy and further management:
 Surgery
 Radiotherapy
 Chemotherapy
 Palliative care
Aboubakr Elnashar

55. Conclusions
Visual Inspection Techniques in Low resource setting
 Noninvasive, easy to perform, inexpensive
 All requirements are available locally
 Can be performed by all levels of healthcare workers,
in almost any setting
 Accuracy is comparable to Pap smear.
 Results are available immediately
 Initial treatment can be provided at the time of the
examination
Aboubakr Elnashar

56. Thank you
Aboubakr Elnashar