How do you diagnose cervical polyps?

Distinguishing Cervical Polyps from Other Cervical Growths

Cervical polyps are best distinguished from other cervical growths through colposcopy with targeted biopsy, which allows for direct visualization and histological confirmation of the lesion. Proper identification is crucial as cervical polyps are typically benign but must be differentiated from potentially malignant lesions.

Clinical Characteristics of Cervical Polyps

• Appearance: Cervical polyps typically appear as small, smooth, red or purple finger-like growths attached to the cervix by a slender stalk (pedicle) 1, 2
• Size: Usually range from pea to cherry size, though giant polyps can occur rarely 3
• Location: May protrude from the endocervical canal or be attached to the ectocervix 1
• Symptoms: Often asymptomatic (60% of cases), but may cause:
  • Intermenstrual bleeding
  • Postcoital bleeding
  • Heavy menstrual bleeding
  • Postmenopausal bleeding
  • Vaginal discharge 1, 4

Diagnostic Approach

1. Initial Evaluation

• Visual inspection during speculum examination
• Cervical cytology (Pap smear) - note that polyps themselves are unlikely to be associated with dysplasia, but concurrent screening is important 4
• HPV testing - particularly for high-risk types (16,18,45) which warrant immediate evaluation due to higher risk of underlying cervical intraepithelial neoplasia 5

2. Colposcopy Examination

Colposcopy is the gold standard for distinguishing cervical polyps from other growths:

• Technique: Examination of cervix after application of 3-5% acetic acid solution 6, 5
• Key features of polyps on colposcopy:
  • Smooth surface with visible blood vessels
  • No acetowhite changes (unlike CIN lesions)
  • Visible stalk or pedicle
  • May bleed easily when touched

3. Differential Diagnosis

Cervical polyps must be distinguished from:

• Cervical intraepithelial neoplasia (CIN): Shows acetowhite changes on colposcopy
• Cervical cancer: Irregular, friable, bleeding lesion with abnormal vessels
• Nabothian cysts: Smooth, dome-shaped, yellowish lesions
• Endometrial polyps: Originate from uterine cavity (hysteroscopy may be needed to determine origin) 1
• Condyloma (genital warts): Multiple, irregular, cauliflower-like lesions

Confirmatory Diagnostic Procedures

1. Colposcopy-Directed Biopsy

• Multiple biopsies (minimum of two) should be taken from the worst abnormal-looking areas 5
• If colposcopy is satisfactory (entire squamocolumnar junction visible), targeted biopsy is sufficient 6
• If colposcopy is unsatisfactory, endocervical curettage (ECC) should be performed in addition to directed biopsy 6

2. Hysteroscopy

• Particularly valuable to determine the exact origin of the polyp (cervical vs. endometrial) 1
• Important when a patient presents with abnormal uterine bleeding
• Can identify concurrent endometrial polyps (present in up to 25% of patients with cervical polyps) 1

3. Histopathological Examination

• Essential for definitive diagnosis
• Rules out malignancy (which occurs in approximately 1.7% of cervical polyps) 3
• Should be performed after removal of all cervical polyps 2

Management Based on Diagnostic Findings

• Asymptomatic polyps: Can be removed as an outpatient procedure 7, 4
• Symptomatic polyps: Removal with histopathological examination is recommended 7
• Technique options:
  • Simple polypectomy with ring forceps (can be performed by primary care providers) 4
  • Hysteroscopic polypectomy (more precise, especially for polyps with unclear origin) 1

Common Pitfalls to Avoid

1. Incomplete removal: Simple twisting or avulsion may leave residual polyp fragments in the cervical canal 1
2. Misidentification of origin: Difficulty differentiating endocervical from endometrial lesions without hysteroscopy 1
3. Missing concurrent pathology: Up to 25% of patients with cervical polyps have coexisting endometrial polyps 1
4. Inadequate follow-up: Patients with cervical polyps should still participate in routine cervical cancer screening 4

By following this systematic approach to diagnosis, clinicians can accurately distinguish cervical polyps from other cervical growths and provide appropriate management.