All gynaecologists have experienced the dreaded “where is the cervix?” moment in colposcopy. This is a moment when the speculum is inserted into the vagina and, despite our expert technique, it is difficult to achieve an accurate view of the cervix. And, of course, often a medical student is peering over our shoulder watching with admiration and eagerly awaiting the moment the cervix is in view.

This year, I had two clinical cases where the cervix was obstructed by a left-lateral vaginal cyst. Vaginal Gartner’s duct cysts are relatively uncommon and reported to occur in only 1% to 2% of women.^1,2 Thus, when I encountered two in the same year, both at the time of colposcopy, it seemed a great learning opportunity to share with my peers.

Benign vaginal cysts are usually asymptomatic and often found incidentally at the time of a clinical examination. Vaginal cysts are classified by the histological type of epithelium that lines the cyst wall. For example, Bartholin’s duct cysts are lined by transitional, mucin-rich columnar or squamous epithelium, whereas Gartner’s duct cysts are lined by non-mucinous cuboidal epithelium. Gartner’s cysts are typically situated on the left-lateral vaginal wall.^1,2

Case 1

The first colposcopy case involved a 38-year-old patient with an abnormal cervical screening test (CST) that identified persistent human papillomavirus (HPV) other (not 16/18). Her most recent CST, collected by her general practitioner (GP), reported a negative liquid-based cytology (LBC), however the endocervical component (ECC) was absent.

Fig. 1. Vaginal left lateral wall cyst.

At the beginning of the patient’s examination, a left lateral wall reducible and non-tender cyst was encountered completely obstructing the view of the cervix (Figure 1). It would be necessary to move the cyst out of the field of vision while keeping both hands free to conduct the colposcopy examination. To do this, an ultrasound probe cover was placed over the speculum. Sterile scissors were then used to cut a small hole overlying the distal end of the speculum. After the speculum was inserted into the vagina, it was opened carefully to allow only the cervix to be seen while the vaginal walls were held-back out of view. This adequately excluded the vaginal cyst to allow accurate assessment of the transformation zone (Figure 2).

Fig. 2. Cervix in view after speculum covered.

Two high-grade acetowhite lesions were identified and cervical biopsies were taken. The histopathology report confirmed high grade squamous intraepithelial lesion (HSIL/CIN2) and HPV infection. After obtaining informed consent, the patient proceeded to a large loop excision of the transformation zone (LLETZ). As the vaginal cyst was asymptomatic, we decided to forgo cystectomy at the time of LLETZ. Once the final LLETZ histology is available, we will review the option of vaginal cystectomy.

Case 2

A 52-year-old patient was referred to me by their GP for a Mirena replacement under general anaesthesia. The patient had the Mirena inserted for contraception, and it had been in situ for nearly six years. The patient had a normal cervical cancer screening history and was due for their routine CST.

The patient reported symptoms consistent with menopause and amenorrhea while using the current Mirena. It was discussed that replacement of the Mirena may not be required. The patient was also eligible for a self-collected vaginal CST. Following receipt of the CST result, we could plan the next management steps.

The self-collected CST detected HPV other (not 16/18), and LBC was therefore required. It was offered that LBC be collected during a colposcopy examination, with concurrent removal of the Mirena in the outpatient setting. During insertion of the speculum, the cervix could not be visualised due to a left-lateral vaginal cyst. At the time of the examination, the patient confirmed knowledge of the cyst, stating it had been present for many years and never bothersome.

The same technique was used as in the first case, with an ultrasound probe cover placed over the speculum and the distal end cut open. An accurate view of the cervix was obtained, LBC collected, and colposcopy completed. No abnormal cervical lesions were seen and no biopsies were taken. Interestingly, the Mirena strings were not visible, and attempted removal of the device was declined. The cytology report concluded a low-grade intraepithelial lesion with ECC present. We discussed treatment options, and the patient will continue conservative management for the cyst with repeat CST next year.

Treatment with LLETZ

The ultrasound probe cover technique worked like a charm in the clinic; however, how would I complete a LLETZ without inadvertently traumatising the vaginal cyst? Probe covers are typically made of latex, polyethylene, or polyurethane, all of which are flammable and not ideal material to place beside a wire loop heated by electrical current!

Fig. 3. Insulated speculum and lateral vaginal retractor.

Fig. 4. Demonstration of simultaneous usage of instruments for LLETZ.

To conduct a LLETZ procedure and avoid trauma to the lateral vaginal wall, two separate insulated instruments were used (Figures 3 and 4). First, a lateral vaginal retractor was placed with the handle upward and held by an assistant. The vaginal cyst was pushed back out of the surgical field. Next, a bi-valve speculum was inserted in between the arms of the lateral retractor. This allowed accurate visualisation and successful loop excision without damage to the cyst or vaginal wall (Figure 5).

Fig. 5. Vaginal cyst retracted and cervix in view before LLETZ.

When the vaginal walls are obstructing the full view of a cervix, it is possible to obtain a clear view using a cover over the speculum, such as an ultrasound probe cover or condom. This is a familiar technique for most gynaecologists. However, these cases are unique because there was a large unilateral vaginal cyst obstructing the cervical view at the time of colposcopy.

A lateral vaginal retractor can be very useful during a LLETZ procedure to reduce inadvertent trauma to the vagina. The retractor is usually secured with the handle locked in a downward position to allow independence of the surgeon. In this case, the unilateral cyst required a slightly asymmetrical angle of retraction best achieved by an assistant holding the handle upwards.

These cases made me reflect upon the accuracy of the CST for each of these patients. In the first case, the LBC was negative with ECC absent, and the patient had HSIL confirmed with biopsy. The second case involved a self-collected CST.

The Australian National Cervical Screening Program (NCSP) expanded self-collection eligibility in 2022 to include all people with a cervix aged 25 to 74 years. This has substantially increased screening in under-screened populations. Furthermore, research has confirmed the accuracy and efficacy of HPV testing on self-collected samples compared to clinician-collected samples.^3,4

Certainly, the self-collect option is an important contribution to the NCSP, allowing autonomy and equity in cervical cancer screening, and Australia has led the way for improving cervical cancer screening programs globally. Based on my experience with these two cases, it may be important to consider anatomical variants and vaginal cysts when discussing and consenting patients for self-collected vaginal samples.