Pseudo Vaginoscopy: A Modified Vaginoscopy Technique for Outpatient Hysteroscopy in Cases with Difficult Access

Background: Outpatient hysteroscopy is a safe, reliable and cost-effective alternative to hysteroscopy under a general anaesthetic for the diagnosis of abnormal uterine bleeding. Objectives: The objective of this study was to introduce new technique of pseudo-vaginoscopy for Original Research Article Memon better movement of hysteroscope and less procedural pain. Also to assess acceptability of patients for outpatient hysteroscopy when appropriate analgesia was given prior to the procedure. Methodology: A prospective study was conducted of 74 women attending for outpatient hysteroscopy at the West Cumberland Hospital over a period of one year. Selection criteria include very narrow and atrophic vagina and failed speculum examination in gynaecology outpatient clinics. Results: Of the women studied, 95.5% stated that they would recommend the procedure to friends in future, whilst 5.8% would not want to go through it again. The type of anaesthetic administered during the procedure seem to influence whether women would attend for outpatient hysteroscopy in future. Conclusion: Our pseudo-vaginoscopic approach allows more freedom for the scope movements not limited by the speculum with the advantage of prior cervical preparation. It was certainly at value for operative outpatient hysteroscopy in patients with very high BMI where access was difficult owing to depth.


INTRODUCTION
Outpatient hysteroscopy is an established diagnostic test that is in widespread use across the UK.
It is indicated preliminarily in the assessment of women with abdominal uterine bleeding [1].
More recently advances in endoscopic technology and ancillary instrumentation have facilitated the development of operative hyteroscopic procedures in an outpatient setting with or without the use of local anaesthesia [2].
However, as with any procedure requiring instrumentation of the uterus outpatient hysteroscopy can be associated with significant pain anxiety and embarrassment [3].
This not only impacts upon women's satisfaction with their experience, but also limits the feasibility and possibly the safety accuracy and effectiveness of the procedure [4].
To minimise pain and discomfort, variations in hysteroscopic equipment adaptations to the technique and use of pharmacological agents have been advocated [5].
Vaginoscopy refers to a technique where the hysteroscope is introduced into the vagina through the cervical canal and into the uterine cavity without the need for a vaginal speculum or cervical instrumentation. Vaginoscopy technique requires thinner scopes and avoids potential vaginal and cervical manipulation. However, there is unknown chance of success given potential cervical stenosis and missing the benefits of cervical block [6].
Vaginoscopy is the recommended standard technique for outpatient hysteroscopy, especially where successful insertion of a vaginal speculum is anticipated to be difficult and where blind endometrial biopsy is not required [7].
Vaginoscopy confers the advantage of increased external movement of the hysteroscope and is associated with significantly less procedural pain however the feasibility of Vaginoscopy in relation to the characteristics of the woman such as body mass index, menopausal status and parity are less well studied.
These characteristics inevitably call for a modification to the standard technique to reap the advantages of the vaginoscopic approach minimising the risk of failure of procedure [8].

METHODOLOGY
A prospective audit was conducted on 74 women attending for outpatient hysteroscopy at the West Cumberland Hospital over a period of one year. Selection criteria include very narrow and atrophic vagina and failed speculum examination in gynaecology outpatient clinics. Data were analysed using SPSS version 22.

Technique
1. Local anaesthetic gel is used to prepare the vagina to allow Cusco's speculum and cervical preparation 2. Cervical block to prepare the cervix 3. Cervical dilatation (if required) after stabilisation with tenaculum 4. Then, there is the option of withdrawing all instruments to allow vaginoscopic approach (with the cervix prepared and accessible) OR 5. If cervical traction is required, passing another tenaculum sideways through the speculum's blades to hold the cervix and then disengaging the other instruments.

RESULTS AND DISCUSSION
Seventy four (74) women were selected for this prospective study. Psuedovaginoscopy was performed in all of them and a patient satisfaction survey was performed from the participants after the completion of procedure. This technique was perfected over 20 hysteroscopy episodes before it was standardised to be studied at our outpatient hysteroscopy suite for cases with difficulties in access.
The majority women were under the BMI of 30 and the principal indication of referral was postmenopausal bleeding. The women selected for this study had narrow and stenosed vagina and failed examination with speculum when seen in gynaecology outpatient clinics.
Pseudovaginoscopy performed in all the cases by using technique as mentioned above. The rate of accessing the cavity was 100%.Failure to remove pathology in the actual episodes 3/74 (4.1%). One could not tolerate pain, in other patient polyp cut but could not retrieve. In the last case pathology could not be removed. All of the failed cases underwent hysteroscopy under GA.
After the procedure a patient satisfaction survey was conducted. Sixty eight women replied out of 74. Sixty five (95.5%) would recommend it if done this way to a friend. Four women (5.8%) showed dissatisfaction due to pain during the procedure and would not want to go through it again.
Our technique of pseudo-vaginoscopy and results of the study have shown that all the patient who had optimum analgesia in the form of local anaesthetic gel in the vagina tolerated speculum examination. We used instillagel as local anaesthetic gel. The primary outcome measures included [9] success of the procedure, defined as adequate inspection of the entire endometrial cavity including the uterine cornua, tubal ostia, uterine fundus, lateral walls, anterior and posterior walls, and cervical canal); [10] duration of hysteroscopy, defined as the interval between introduction of the speculum to completion of diagnostic hysteroscopy using the traditional approach or introduction of the hysteroscope using the vaginoscopic approach; [11] duration of endometrial biopsy, defined as the interval between completion of the diagnostic hysteroscopy and removal of the biopsy device from the uterine cavity; [12] adequacy of endometrial biopsy; and [13][14] adverse events.
The secondary outcome measure was pain score using a 10-point visual analog scale: 0 = no pain; 10 = worst possible pain. Women were asked to give pain scores before, during and immediately after the procedure by a nurse who scored their degree of pain during the procedure. Before discharge from the hospital, women were interviewed about their experience with the procedure in terms of acceptability (very acceptable, fairly acceptable, or not acceptable), whether they would recommend the procedure to a friend who required the procedure (yes or no), and whether they would agree to haveoutpatienthysteroscopy with pseudo-vaginoscopyif they needed the same procedure in the future.
Few studies have been published in the literature where different modalities were applied to reduce pain during the procedure and improves patient satisfaction.

CONCLUSION
Our pseudo-vaginoscopic approach allows more freedom for the scope movements not limited by the speculum with the advantage of prior cervical preparation.
It was certainly at value for operative outpatient hysteroscopy in patients with very high BMI where access was difficult owing to depth.
Pseudo-vaginoscopy eliminates the risk of missed cancers of vulva, vagina and cervix, readily appreciated by naked eye inspection of the vulva and speculum examination.

CONSENT
As per international standard or university standard, patients' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).