Chapter 2

Testing and reporting the results of visualinspection with 5% acetic acid (VIA)

Test provider skillsThe test provider must have a goodknowledge of the anatomy, physiology andpathology of the cervix in relation to itsvisual examination. He/she should knowthe clinical features of benign conditions,inflammation, precancerous lesions andinvasive cancer of the cervix.

ProcedureWomen coming for testing should have thescreening procedure explained to them indetail. Written informed consent should beobtained before screening. An example ofa written informed consent form is given inAppendix 2. Relevant obstetric andgynaecological history should be obtainedand recorded with the help of a form forthis purpose (Appendix 3). The womanshould be reassured that the procedure ispainless, and every effort should be madeto ensure that she is fully relaxed andremains at ease during testing.

The woman is invited to lie down in amodified lithotomy position on a couchwith leg rests or knee crutches orstirrups. After proper positioning of thewoman, observe if there is any vaginaldischarge. Observe the external genitalia and perineal region for anysigns of excoriations, oedema, vesicles,papules, sores, ulceration and warts.

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Instruments and materials required:• Examination table with knee crutches or

leg rests or stirrups;

• Good light source (preferably a bright

halogen lamp that can be easily directed

at the cervix or a bright halogen torch

light);

• Sterile bivalved speculum: Cusco’s,

Grave’s or Collin’s;

• Pair of gloves;

• Cotton swabs, cotton-tipped buds, gauze;

• Ring forceps, pickup forceps;

• 5% freshly prepared acetic acid or vinegar

(check the strength of acetic acid in

vinegar);

• A steel/plastic container with 0.5%

chlorine solution in which to immerse the

gloves;

• A plastic bucket or container with 0.5%

chlorine solution to decontaminate

instruments;

• A plastic bucket with a polythene bag to

dispose of contaminated swabs and other

waste items.

Preparation of 5% dilute acetic acid5% acetic acid is prepared by adding 5 ml of

glacial acetic acid into 95 ml of distilled

water.

If vinegar bought from a store is used, check

the strength to ensure that it is 5%.

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Look for any swelling in theinguinal/femoral region.

Afterwards, gently introduce a sterilevaginal speculum which has beenimmersed in warm water and open theblades of the speculum to view thecervix. Adjust the light source so thatthere is adequate light in the vagina andon the cervix. As the speculum is gentlyopened and the lips are fixed, the cervixcomes into view. Observe the size andshape of the cervix.

Identify the external os, columnarepithelium (red in colour), squamousepithelium (pink) and thesquamocolumnar junction. Proceed toidentify the transformation zone, theupper limit of which is formed by thesquamocolumnar junction. Rememberthat cervical neoplasias occur in thetransformation zone nearest to thesquamocolumnar junction.

Look for ectropion, cervical polyp,nabothian cysts, healed laceration of thecervical lips, leukoplakia, condylomataand signs of cervicitis. You may note thatin postmenopausal women, the cervixappears pale and brittle, due to thinningand atrophy of the squamous epithelium.Assess the characteristics of discharge interms of quantity, colour, odour andthickness. Thread-like, thin mucinousdischarge from the external os indicatesovulation. If heavy blood flow through theexternal os is observed in women duringmenstruation, they may be subjected toVIA after 5-15 days.

In ectropion, the cervix has a large areaof red appearance around the external osand the squamocolumnar junction faraway from the os. Nabothian cysts appearas bulging blue-white or yellow-whitenodules, having a smooth delicate liningwith branching blood vessels. In some

women, nabothian cysts can become largeand distort the shape of the cervix. Acervical polyp appears as a smooth massprotruding from the cervical canal beyondthe external os, which may appear darkred or pink-white. Sometimes a necroticpolyp resembles a cervical cancer. Healedlacerations appear as tears on the lips ofthe cervix, with the external os appearingirregular. Leukoplakia appears as asmooth-surfaced, white area on the cervixthat cannot be removed or scraped off.Cervical condylomata appear as raised,grey-white areas within or outside thetransformation zone in the squamousepithelium and may be accompanied bysimilar lesions in the vagina and vulva.

Look for small blisters containing fluid ormultiple, small ulcers on the cervix.Extensive erosive red areas may be presenton the cervix, extending to the vagina ininstances of severe cervical infection andinflammation. Observe whether there isany bleeding from the cervix, especially ontouch, or ulceroproliferative growth. Avery early invasive cancer may present as arough, reddish, granular area that maybleed on touch. More advanced invasivecancers may present as a large exophyticgrowth with an ulceroproliferative, bulgingmass with polypoid or papillaryexcrescences, arising from the cervix or asa predominantly ulcerating growthreplacing most of the cervix. In both ofthese types, bleeding on touch and necrosisare predominant clinical features. Foul-smelling discharge is also common due tosuperadded infection. Occasionally,invasive cancer can present as aninfiltrating lesion with a grossly enlargedirregular cervix.

Now, gently, but firmly, apply 5% aceticacid using a cotton swab soaked in aceticacid. The secretions should be gently wiped

A Practical Manual on Visual Screening for Cervical Neoplasia

off. The swabs after use should be disposedof in the waste bucket. The curdy-whitedischarge associated with candidiasis isparticularly sticky, and if particular care isnot taken to remove it properly, it maymimic an acetowhite lesion, thus leading toa false-positive result. After removing theswab, carefully look at the cervix to seewhether any white lesions appear,particularly in the transformation zoneclose to the squamocolumnar junction, ordense, non-removable acetowhite areas inthe columnar epithelium. The results oneminute after application of acetic acidshould be reported. Note how rapidly theacetowhite lesion appears and thendisappears.

Carefully observe:• The intensity of the white colour of

the acetowhite lesion: if it is shiny-white, cloudy-white, pale-white ordull-white.

• The borders and demarcations of thewhite lesion: distinctly clear and sharpor indistinct diffuse margins; raised orflat margins; regular or irregularmargins.

• Whether the lesions are uniformlywhite in colour, or the colour intensityvaries across the lesion, or if there areareas of erosion within the lesion.

• Location of the lesion: is it in, near orfar away from the transformationzone? Is it abutting (touching) thesquamocolumnar junction? Does itextend into the endocervical canal?Does it occupy the entire, or part of,the transformation zone? Does itinvolve the entire cervix (whichusually indicates early preclinicalinvasive cancer)?

• Size (extent or dimensions) andnumber of the lesions.

If in doubt, it is safe to repeat the test afew times, taking care not to inducebleeding. Women with suspected invasivecancers should be referred for furtherinvestigations and treatment.

Conclusion of the examinationContaminated swabs, gauze and otherwaste material should be disposed of inthe plastic bag in the plastic bucket.

Withdraw the speculum gently, andinspect the vaginal walls for condylomaand acetowhite lesions. Before removingthe soiled gloves, immerse the handsbriefly in a container filled with 0.5%chlorine solution. Decontaminate theused gloves by soaking in the 0.5%chlorine in a plastic bucket for 10minutes. Preparation of 0.5% chlorinesolution is described in Appendix 4.

The speculum and other instrumentsused for VIA should be immersed in 0.5%chlorine solution for 10 minutes’ deconta-mination, before cleaning with detergentand water. The cleaned instruments maybe reused after high-level disinfection byimmersing them in boiling water for 20minutes or by sterilizing the instrumentsusing an autoclave.

Documentation of findings andadvising the womanCarefully document the outcome oftesting in the reporting form (Appendix3). Explain the outcome of the test tothe woman, as well as any further courseof follow-up actions. If the test isnegative, the woman is reassured and shemay be advised to repeat testing afterfive years. If the test is positive, sheshould be referred for furtherinvestigations such as colposcopy andbiopsy as well as treatment for anyconfirmed lesions. If invasive cancer is

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Chapter 2

18

suspected, she should be referred to acancer diagnosis and treatment facility.

Reporting the outcome of VIAVIA negative (-)VIA screening is reported as negative inthe case of any of the followingobservations:• No acetowhite lesions are observed on

the cervix (Figure 2.1).• Polyps protrude from the cervix with

bluish-white acetowhite areas (Figure2.2).

• Nabothian cysts appear as button-likeareas, as whitish acne or pimples(Figure 2.3).

• Dot-like areas are present in theendocervix, which are due to grape-like columnar epithelium staining withacetic acid (Figure 2.4).

• There are shiny, pinkish-white, cloudy-white, bluish-white, faint patchy ordoubtful lesions with ill-defined,indefinite margins, blending with therest of the cervix (Figures 2.5-2.7).

• Angular, irregular, digitatingacetowhite lesions, resemblinggeographical regions, distant(detached) from the squamocolumnarjunction (satellite lesions) (Figure 2.8).

• Faint line-like or ill-definedacetowhitening is seen at thesquamocolumnar junction (Figures2.8-2.10).

• Streak-like acetowhitening is visible inthe columnar epithelium (Figure 2.8).

• There are ill-defined, patchy, pale,discontinuous, scattered acetowhiteareas (Figures 2.10-2.11).

A Practical Manual on Visual Screening for Cervical Neoplasia

FIGURE 2.1: VIA negative: No acetowhite area seen. Notethe advancing edges of squamous metaplasiain the anterior and posterior lips (arrows).

FIGURE 2.2: VIA negative. There are no acetowhite areason the polyp and the cervix after theapplication of acetic acid.

↓↓

↓

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Chapter 2

FIGURE 2.6: VIA negative: There is an ill-defined pinkish-white hue with indefinite margins blendingwith the rest of the epithelium. Thesquamocolumnar junction is fully visible.

FIGURE 2.3: VIA negative. The nabothian cysts appear aspimple- or button-like areas after theapplication of acetic acid.

FIGURE 2.4:VIA negative: There is dot-likeacetowhitening in the columnar epithelium inthe anterior lip. The squamocolumnarjunction is fully visible.

FIGURE 2.5: VIA negative: There are ill-defined pinkish-white and cloudy-white areas with indefinitemargins blending with the rest of theepithelium. The squamocolumnar junction isfully visible.

↓

↓↓

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A Practical Manual on Visual Screening for Cervical Neoplasia

FIGURE 2.7: VIA negative: There is an ill-defined pinkish-white hue, with indefinite margins, blendingwith the rest of the epithelium. Thesquamocolumnar junction is fully visible.

FIGURE 2.8: VIA negative: There are pale white, satellite,geographical lesions with angular margins(narrow arrow) far away from thesquamocolumnar junction (dense arrow).Note the streak-like acetowhitening in thecolumnar epithelium (within the oval area).

FIGURE 2.9: VIA negative: There is dense, thick, mucus on the cervix before the application of acetic acid.After the application of acetic acid, the mucus is cleared and the squamocolumnar junctionbecomes prominent.

↓ ↓↓

VIA positive (+) The VIA test outcome is reported aspositive in any of the following situations:• There are distinct, well-defined,

dense (opaque, dull- or oyster-white)acetowhite areas with regular orirregular margins, close to orabutting the squamocolumnarjunction in the transformation zoneor close to the external os if thesquamocolumnar junction is notvisible (Figures 2.12-2.20).

• Strikingly dense acetowhite areas areseen in the columnar epithelium(Figures 2.21-2.22).

• The entire cervix becomes denselywhite after the application of aceticacid (Figure 2.23).

• Condyloma and leukoplakia occurclose to the squamocolumnarjunction, turning intensely white afterapplication of acetic acid.

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Chapter 2

FIGURE 2.10: VIA negative: The squamocolumnar junctionis prominent after the application of aceticacid. Note the ectropion.

FIGURE 2.11: VIA negative: The cervix is unhealthy,inflamed with ulceration, necrosis, bleedingand inflammatory exudate.There is ill-defined,diffuse, pinkish-white acetowhitening withindefinite margins blending with the rest ofepithelium (arrows).

FIGURE 2.12: VIA positive: There is a well-defined, opaqueacetowhite area, with irregular digitatingmargins, in the anterior and posterior lipsabutting the squamocolumnar junction andextending into the cervical canal.

↓↓

↓

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A Practical Manual on Visual Screening for Cervical Neoplasia

FIGURE 2.13: VIA positive: There is a well-defined, opaqueacetowhite area, with bleeding on touch, inthe anterior lip, abutting thesquamocolumnar junction, which is fullyvisible.

FIGURE 2.14: VIA positive: There is a well-defined, opaqueacetowhite area, with regular margins, in theanterior lip, abutting the squamocolumnarjunction, which is fully visible.

FIGURE 2.15: VIA positive: There is a well-defined, opaqueacetowhite area, with regular margins, in thelower lip, abutting the squamocolumnarjunction, which is fully visible.

FIGURE 2.16: VIA positive: There is a well-defined, opaqueacetowhite area, with regular margins, in theanterior lip, abutting the squamocolumnarjunction, which is fully visible. Note thesatellite lesions in the lower lip.

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Chapter 2

FIGURE 2.17: VIA positive: There is a well-defined,opaque acetowhite area, with regularmargins, in the anterior lip, abutting thesquamocolumnar junction, which is fullyvisible. Note the somewhat ill-defined whitearea in the lower lip. The lesion is extendinginto the cervical canal.

FIGURE 2.18: VIA positive: There is a well-defined, dull,dense, opaque acetowhite area in the anteriorlip abutting the squamocolumnar junctionwhich is fully visible.

FIGURE 2.19: VIA positive: There is a well-defined, dull,dense, opaque acetowhite area, with raisedand rolled-out margins in the anterior lipabutting the squamocolumnar junctionwhich is fully visible. The lesion is extendinginto the cervical canal.

FIGURE 2.20: VIA positive: There is a well-defined, dull,dense, opaque acetowhite area in theposterior lip extending into the endocervicalcanal.

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VIA positive, invasive cancerThe test outcome is scored as invasivecancer when:• There is a clinically visible ulcero-

proliferative growth on the cervix thatturns densely white after applicationof acetic acid and bleeds on touch(Figures 2.24-2.27).

Self-evaluation of the testprovidersThe test providers are encouraged tocorrelate the results of their VIA testingwith those of colposcopy and histology.They are strongly advised to participatein the colposcopy sessions with doctorsand review the findings. Such measuresimprove the skills of the test providers.A benchmark to assess one’s own skill isto estimate what proportion of womenexamined are scored as aceto-positiveand what proportion of aceto-positive

A Practical Manual on Visual Screening for Cervical Neoplasia

FIGURE 2.21: VIA positive: There is an acetowhite area inthe columnar epithelium in the anterior andposterior lips.

FIGURE 2.22: VIA positive: There are dense acetowhiteareas in the columnar epithelium in theanterior lip.

FIGURE 2.23: VIA positive: There is a dense acetowhite areaall over the cervix involving all the fourquadrants and extending into the cervicalcanal.

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Chapter 2

FIGURE 2.25: VIA positive, invasive cancer: There is aproliferative growth with denseacetowhitening and bleeding.

FIGURE 2.26: VIA positive, invasive cancer: There is adense acetowhite area with irregular surfacecontour.

FIGURE 2.24: VIA positive, invasive cancer: There is a dull,opaque, dense acetowhite area, with raisedand rolled-out margins, irregular surface andbleeding on touch in the posterior lip. Thelesion is extending into the cervical canal.The bleeding obliterates acetowhitening.

FIGURE 2.27: VIA positive, invasive cancer: There is an ulceroproliferative growth withacetowhitening and bleeding.

women are ultimately diagnosed withCIN. A sufficiently skilled examiner willcategorize 8-15% of women examined asaceto-positive, and 20-30% of the

acetowhite lesions identified on VIA bythe test provider harbour CIN of anygrade.

A Practical Manual on Visual Screening for Cervical Neoplasia

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