Atlas of Primary Care Procedures, 1st Edition

Gynecology and Urology

36

Cervical Polyp Removal

Cervical polyps are pedunculated tumors that commonly arise from the mucosa of the endocervical canal. They are usually bright red and have a soft, spongy structure. Cervical polyps are common and are most often seen in perimenopausal and multigravid women in the third through fifth decades of life. The cause of most polyps is unknown, but they are associated with increasing age, inflammation, trauma, and pregnancy.

The histology of cervical polyps is similar to that of the endocervical canal, with a single tall columnar cell layer and occasional cervical glands. Vascular congestion, edema, and inflammation are frequently present. Many endocervical polyps demonstrate squamous metaplasia, which may cytologically and colposcopically mimic dysplasia. Squamous dysplasia and cancer may originate on cervical polyps, but malignant degeneration is rare. However, if a polyp is discovered after an atypical Papanicolaou (Pap) smear, the polyp should be sent for pathologic study, especially if it contains any acetowhite epithelium.

Polyps are often asymptomatic and are typically found at the time of the routine gynecologic examination. They may be single or multiple and may vary in size from a few millimeters to several centimeters. Rarely, the pedicle can become so elongated that the polyp protrudes from the vaginal introitus. There may be vaginal discharge associated with cervical polyps, especially if the polyp becomes infected. Ulceration of the tip and vascular congestion often result in postcoital or dysfunctional uterine bleeding. Larger polyps may bleed periodically, producing intermenstrual spotting and postcoital bleeding. Valsalva straining also may stimulate bleeding. Symptoms may be exactly the same as in the early stages of cervical cancer.

There is an association between cervical and endometrial polyps. Postmenopausal women with cervical polyps have a higher incidence of coexisting endometrial polyps that is unrelated to hormone replacement therapy. Patients on tamoxifen therapy have a very high association of cervical polyps with endometrial polyps and probably should be evaluated with dilatation and curettage. However, most physicians perform simple polypectomy in the office if the patient is otherwise asymptomatic. The differential diagnosis for cervical polyps is shown inTable 36-1.

TABLE 36-1. DIFFERENTIAL DIAGNOSIS

 

Endometrial polyp

Prolapsed myoma

Incomplete spontaneous abortion

Leiomyosarcoma

Squamous papilloma

Sarcoma

Cervical malignancy

 

Because most polyps are benign, they may be removed or observed on routine examinations. They are often twisted off during routine examinations to reduce

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the incidence of inflammation and incidental bleeding. Polyps may also be removed during dilatation and curettage, by hysteroscopic wire or snare, by electrocautery, during a loop electrosurgical excisional procedure, or by surgical excision.

After removal of a polyp, the patient should avoid sexual intercourse, douching, and tampon usage for several days. A follow-up examination should be done in 1 to 2 weeks to check for problems, if desired. If active bleeding occurs, the patient should be seen immediately. Examination to check for regrowth should be performed at routine gynecologic visits. Unfortunately, recurrence is common.

INDICATIONS

  • Removal of polyps is usually indicated to prevent irritation, vaginal discharge, and bleeding.

CONTRAINDICATIONS

  • Because the cervix is highly vascularized during pregnancy, polyps should be observed if they are stable and appear benign. They should be removed only if they are causing bleeding.

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PROCEDURE

Perform a standard gynecologic examination. Gently grasp the polyp with ring forceps, apply slight traction, and twist repeatedly until it falls off. If a significant amount of the base of the polyp remains, it may be scraped off with a curette.

 

(1) Gently grasp the polyp with ring forceps, apply traction, and twist until it falls off.

PITFALL: Be sure to identify the location of the base of the polyp to exclude the possibility of an endometrial polyp, which may produce extensive bleeding. If the pedicle extends too deeply to be easily visualized, a Kogan endocervical speculum and colposcopic magnification are often helpful.

Alternatively, a small polyp may be scraped off in its entirety with a sharp curette or biopsied off with a Tischler biopsy forceps. Bleeding is usually self-limited but can be controlled with pressure, Monsel's solution, or cautery.

 

(2) Alternatively, a small polyp may be biopsied off with a Tischler biopsy forceps.

PITFALL: If multiple polyps, irregular bleeding, or ongoing tamoxifen therapy is noted, it may be prudent to remove the polyps while performing dilatation and curettage.

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CODING INFORMATION

There is no separate CPT® code for cervical polyp removal. Some practitioners report polypectomy with 57500* (cervix uteri biopsy) or 57505 (endocervical curettage). If the colposcope is used to identify the polyp base, 57452* can be used to report services.

INSTRUMENT AND MATERIALS ORDERING

Ring forceps, curettes, Kogan's endocervical speculums, and cervical biopsy forceps may be ordered from companies listed in Chapter 37. A suggested anesthesia tray that can be used for this procedure is listed in Appendix G.

BIBLIOGRAPHY

Abramovici H, Bornstein J, Pascal B. Ambulatory removal of cervical polyps under colposcopy. Int J Gynaecol Obstet 1984;22:47–50.

Coeman D, Van Belle Y, Vanderick G, et al. Hysteroscopic findings in patients with a cervical polyp. Am J Obstet Gynecol 1993;169:1563–1565.

David A, Mettler L, Semm K. The cervical polyp: a new diagnostic and therapeutic approach with CO2 hysteroscopy. Am J Obstet Gynecol1978;130:662–664.

Di Naro E, Bratta FG, Romano F, et al. The diagnosis of benign uterine pathology using transvaginal endohysterosonography. Clin Exp Obstet Gynecol 1996;23:103–107.

Golan A, Ber A, Wolman I, et al. Cervical polyp: evaluation of current treatment. Gynecol Obstet Invest 1994;37:56–58.

Goudas VT, Session DR. Hysteroscopic cervical polypectomy with a polyp snare. J Am Assoc Gynecol Laparoscopists 1999;6:195–197.

Hillard GD. Case for diagnosis: cervical polyp. Mil Med 1978;143:618, 631.

Khalil AM, Azar GB, Kaspar HG, et al. Giant cervical polyp: a case report. J Reprod Med 1996;41:619–621.

Lee WH, Tan KH, Lee YW. The aetiology of postmenopausal bleeding—a study of 163 consecutive cases in Singapore. Singapore Med J1995;36:164–168.

Neri A, Kaplan B, Rabinerson D, et al. Cervical polyp in the menopause and the need for fractional dilatation and curettage. Eur J Obstet Gynecol Reprod Biol 1995;62:53–55.

Vilodre LC, Bertat R, Petters R, et al. Cervical polyp as risk factor for hysteroscopically diagnosed endometrial polyps. Gynecol Obstet Invest 1997;44:191–195.