The Vaginoscopical Approach:
25 Years Later
Paola Cramarossa, Fabiana Divina Fascilla, Oronzo Ceci,
and Stefano Bettocchi
1.1 Introduction
When we want to investigate the uterine cavity, the role of
hysteroscopy is not questionable. It has completely unseated
dilatation of the cervical canal, curettage of the cavity, vabra,
and Pipelle. Evolution in the procedure has made it easy to
perform and reduced discomfort for the patient, thus it
became ideal in office regimens [1, 2]. Local anesthesia is no
longer required.
In the past, before our provision, an hysteroscopic
approach needed the use of a speculum to separate vaginal
walls and to visualize the portio and of a tenaculum to sta-
ple the anterior (sometimes posterior) cervical labium to
approach the external cervical orifice. Many endoscopists
used a speculum when performing hysteroscopic evalua-
tion and removed it once the cervix was located and
bypassed. Even when the speculum is the appropriate size,
lubricated, and inserted slowly, it always causes some dis-
comfort, especially in overanxious women.
The tenaculum is used to facilitate and speed up insertion
of the hysteroscope, producing stabilizing countertraction.
Grasping the cervix with the tenaculum is always painful and
traumatic, and the endoscopist tries to avoid it by applying
local anesthetic. Although a paracervical block requires less
than a minute to be performed, it is, in our opinion, not a use-
ful procedure and it may cause the patient additional pain.
After that, the hysteroscope could be inserted in the cervical
canal and give information to the operator by optical vision.
The means of distension was carbon dioxide. These proce-
dures were obviously not applicable to virgos or to women
P. Cramarossa, M.D. • F.D. Fascilla, M.D. • O. Ceci, M.D. •
S. Bettocchi, M.D. (*)
II Unit of Gynecology and Obstetrics, Department “D.I.M.O.”,
University “Aldo Moro” of Bari, Policlinico,
Piazza Giulio Cesare 11, 70124 Bari, Italy
e-mail: stefanoendo@tin.it; stefano.bettocchi@uniba.it
© Springer International Publishing AG 2018
A. Tinelli et al. (eds.), Hysteroscopy, https://doi.org/10.1007/978-3-319-57559-9_1
1
with vaginismus or stenosis of the lower genital tract or heavy
vaginal inflammation because of the impossibility to insert
the speculum properly. Stapling the cervix is very painful for
the patient. Very often the procedure has to be interrupted
without answering the diagnostic or operative questions.
The last 25 years of office hysteroscopy confirmed our
intuition about the possibility—and the need—to abolish
the use of the tenaculum and speculum to visualize the por-
tio, with the great advantage of reducing patient discomfort
and the possibility to perform the examination in virgos or
in patients with vaginal stenosis. In addition, the speculum
could limit the vertical and horizontal movements of the
scope.
In fact, in the presence of a markedly anteflexed or retro-
flexed uterus, the absence of the speculum and tenaculum
seems to enhance correct performance of the technique.
With experience and the possibility to perform wider move-
ments on the vertical axis with the hysteroscope, we are
able to perform hysteroscopy satisfactorily even in these
circumstances. Correct and gradual insertion of the scope,
taking heed of the anatomy of the uterus, can yield the same
technical results without the discomfort produced by exter-
nal factors. At the same time, sensitive awareness allows
the endoscopist to avoid discomfort due to the technical
procedure.
1.2 Procedure
Display of the portio is obtained by introducing a 4 mm hys-
teroscope at the vulvar ostium and letting the solution dilate
the vagina simply by flowing. Rare is the case in which the
endoscopist needs to keep the labia closed to allow the flow
to generate the right pressure to separate vaginal walls. First
of all, this approach allows performing a vaginoscopy: vagi-
nal walls and fornix can be clearly visualized and vaginal
pathology can be highlighted in this venue. Furthermore,
3
4 P. Cramarossa et al.
under the optical guide, following posterior vaginal wall and
fornices, the endoscopist can visualize external uterine os,
helped by flow of mucus coming from the cervix. It may be
difficult to insert the hysteroscope into the cervical canal and
through the internal uterine os if the operator does not under-
stand the correlation between what appears on the screen and
the exact position of the scope in the cervix typical of 30°
fore-oblique vision.
1.3 Instrumentation
Abandoning the CO2 for saline solution, the technique
does not depend on the type of instrument employed. The
Office Hysteroscopes (Karl Storz, Tuttlingen, Germany)
are preferred over flexible fiberoptic instruments or other
micro-­hysteroscopes, because of the higher image quality
typical of this lens-based instrument. In the recent past, the
5 mm hysteroscope was largely used. Nowadays the 4 mm
hysteroscope is, in our opinion, the best instrument. The
smaller diameter causes less discomfort without damage to
vision.
Distention of the vagina and of the uterine cavity is done
with saline solution through the Hamou Endomat liquid
pump (Karl Storz, Tuttlingen, Germany) or, more recently,
Hysteromat EASI (Karl Storz, Tuttlingen, Germany). A
250 W LED light (Karl Storz, Tuttlingen, Germany) is used.
An HD Endocamera is connected to a monitor to transmit the
signal and allow vision.
1.4 Technique
The patient is placed in a dorso-lithotomy position. When
clinical or subclinical signs of vaginal infection are present,
vaginal cytology with contrast-phase microscopy is per-
formed before the endoscopic procedure. This allows the
operator to perform a real-time diagnosis without the need of
a specific culture.
Table 1.1  Comparison of patients’ discomfort with different approaches to diagnostic hysteroscopy
Speculum + Tenaculum,
No anesthesia
Discomfort (%) (n = 49)
No discomfort, pain  2.1
Discomfort, mild pain 53.0
Moderate pain 24.5
Severe pain 20.4b
(procedure suspended)
a
Fibrotic adhesions of the cervix and internal os were present in all women
b
Of these women, 4.1% had a vagal reaction requiring medical assistance
c
Of these patients, 1.2% had a vagal reaction requiring medical assistance
The hysteroscope is then inserted into the vagina. At the
same time, saline solution flows through the hysteroscope
into the vagina. Vaginoscopy and evaluation of shape, disten-
tion, and morphology of vaginal walls are part of the hys-
teroscopic procedure.
The direction of the endocervical canal is determined by
the direction of liquid flow. The hysteroscope is introduced
taking into account the 30° fore-oblique view until the cavity
is entered. A panoramic examination is performed, observ-
ing the fundus, the left and right tubal ostia by rotating the
hysteroscope of 90° clockwise and anticlockwise, and the
anterior and posterior walls by rotating the scope.
Here we report data of the first study we performed 25
years ago to analyze the role of vaginoscopy (Table 1.1). It is
no longer a topic of discussion.
1.5  aginoscopy as a “Standalone”
V
Procedure
Using vaginoscopy to approach the uterus comfortably, a new
world appeared to endoscopists when all possible applica-
tions became clear. Before that, study of the vagina was the
prerogative of manual palpation, visual inspection, and col-
poscopy by using a speculum. Vaginoscopy is nowadays indi-
cated whenever a full and complete vision of vaginal status is
required, a 360° vision, we can say, without discomfort [3, 4].
Easy to guess, pediatric application of vaginoscopy was hap-
pily accepted by the scientific community. Hymenal tissue with
a high estrogen effect (newborns and peripubertal children) is
better able to tolerate iatrogenic stretch without tearing than tis-
sue with a very low estrogen effect (children three to eight years
of age) [5]. Finally, physicians had a powerful instrument to
investigate an organ not previously approachable in any way.
They could immediately get a clear view and even biopsies
without damaging the hymen and violating a child’s maiden-
hood. The diagnostic and legal implications are obvious.
Vulvar and vaginal pathology found a new enemy: (1) benign
neoformations can be distinguished from malignant ones; (2)
Speculum + Tenaculum Speculum only, Vaginoscopy,
+ Anesthesia No anesthesia No anesthesia
(%) (n = 163) (%) (n = 308) (%) (n = 680)
11.7 66.2 96.0
69.3 31.9  4.0a
11.0  1.9 –
 8.0c – –
1  The Vaginoscopical Approach: 25 Years Later
target biopsies become easy to perform; (3) cysts can be identi-
fied and drained at the same time; (4) amplification of the
images can reveal otherwise unseen lesions and direct endosco-
pists about the status of the mucosa, without strictly depending
on histological examination but just being confirmed; (5) stag-
ing of already-known pathologies can be more accurate, such as
endometriosis, advanced endometrial cancer and cervical can-
cer, fistulas; (6) foreign bodies can be removed; (7) in benign
pathology diagnosis is followed by operative treatment in the
same access, such as polyps or vaginal complete or incomplete
septa; (8) sexual abuse or traumas can be deeply investigated;
(9) bleeding can find its origin and sometimes even be stopped;
(10) anatomical abnormalities and intersexual status.
Endoscopists found a strong role even in vaginal pathology.
Conclusions
As we suggested 25 years ago, on the basis of our results
and the widespread consensus, we confirm the vagino-
scopical approach as the gold standard in office hysteros-
copy. There is no doubt that it is an effective, highly
reproducible outpatient diagnostic procedure. By not
using the speculum and the tenaculum before hystero-
scopic examination, we eliminated discomfort not related
to the technique itself, but also reduced the number of
instruments necessary for the procedure [6].
When a liquid distention medium is used, only a small
amount of liquid comes from the vagina and can be collected
5
in a small pouch located under the seat. A small-diameter
scope must be available.
References
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Suggested Reading
Chapa HO, Venegas G. Vaginoscopy compared to traditional hysteros-
copy for hysteroscopic sterilization. A randomized trial. J Reprod
Med. 2015;60(1-2):43–7.