Inspeksi Visual dengan Asam

Asetat : Prosedur & Diagnosis

 Alternatif skrining ?
INSPEKSI VISUAL dengan
ASAM ASETAT (IVA )
 Non –invasif
 Mudah-murah
 Di Puskesmas
 Hasil LANGSUNG
 Sensitivitas,spesifisitas memadai
Kajian di Indonesia
MEMADAISnUNTUK92,31%
NEGARA BERKEMBANG
Sp 98,80%
Akurasi 98,70%

Timbul Bercak putih setelah dipulas dengan asam asetat

 PERBANDINGAN SKRINING TES PAP DAN IVA

Uraian / Metode Skrining TES PAP IVA

Petugas kesehatan Sample takers Bidan

(Bidan/perawat/dokter Perawat
umum/Dr. Spesialis ) Dokter umum
Dr. Spesialis

Skrinner / Sitologist /
Patologist
Sensitivitas 70%--80% 65%-- 96%
Spesifisitas 90%-- 95% 54%-- 98%
Hasil 1 hari–1 bulan Langsung
Sarana Spekulum Spekulum
Lampu sorot Lampu sorot
Kaca benda Asam asetat
Laboratorium
Biaya Rp15.000,00–Rp.75.000,00 Rp. 5.000 – Rp. 15.000
Dokumentasi Ada (dapat dinilai ulang) Ada
 Mengenal SSK

Zona Transformasi SCJ baru

Sambungan
SCJ lama
Skuamo kolumnar=
SSK
Daerah columnar
epithelium

Daerah metaplasti
squamos epithelium

Daerah epithelium
asli
Membuat Asam Asetat 3-5 %
• CUKA DAPUR
(mengandung asam asetat 25%)

• ASAM ASETAT (3-5%)

• Untuk membuat asam asetat 5%

dengan cara mengambil
1 bagian cuka dapur + 4 bagian air

• Untuk membuat asam asetat 3%

dengan cara mengambil
1 bagian cuka dapur + 7 bagian air
Prosedur Pemeriksaan

 Meja ginekologi
(atau MEJA TULIS)
 Sumber cahaya yang
cukup
 Asam asetat 3 - 5 %
 Kapas lidi
 Sarung tangan bersih
(lebih baik steril)
 Spekulum vagina
 Teknik Pemeriksaan IVA 4L
an
Inspekulo gk
ah
1. Curigakanker Tidak curiga kanker

2. SSK ?
Biopsi
Tidak tampak SSK Tampak SSK

KaSIVO Pap Smir 3. IVA

Semua tahap ini dapat dilakukan Negatif Positif

Bidan/Perawat terlatih, Pada tindakan BIOPSI
atau KRIOTERAPI perlu bantuan/ supervisi DOKTER
4. KRIOTERAPI ?
Dokumentasi dengan Kamera Digital

Sebelum asam asetat Setelah asam asetat

Dokumentasi dr. Laila 2007

 Kriteria penilaian IVA

Normal

IVA positif : ditemukan bercak putih

I. Kanker serviks
 Signifikansi Non klinis
Lesi Acetowhite (White Epitel)

Jauh dari SSK Garis putih dekat os

(endoserviks)

Putih pucat Bintik putih pucat pada os

(endoserviks)

Larik acetowhite
Positif
 Alur Pemeriksaan IVA
Inspekulo Servik

Normal Servisitis Positif :Bercak putih Curiga kanker

Ulang Terapi
Terapi Pap Smir RUJUK
berkala KRIOTERAPI
sesuai
Biopsi
Semua tahap ini dapat dilakukan oleh Bidan/Perawat terlatih,
Pada tindakan BIOPSI perlu bantuan DOKTER
 TINDAK LANJUT IVA Positif

Tergantung yang menemukan

Bidan - Tes Pap

Perawat terlatih - Merujuk
Dokter umum

Lesi pra lanker

Langsung KRIOTERAPI(?)
(SEE and TREAT)

Dokter obs - gin Diagnosis

Terapi
VIA-negative
VIA negative. The mild
acetowhite staining in a
linear pattern at the lower
edge of the
squamocolumnar junction
and around the two
glandular crypt openings is
the typical appearance of
immature metaplasia. Used
with permission from
Program for Appropriate
Technology in Health
(PATH). Seattle, WA: PATH.
 VIA-Negative

No acetowhite area seen. Note the There are no acetowhite areas on the
advancing edges of squamous polyp and the cervix after the
metaplasia in the anterior and application of acetic acid.
posterior lips (arrows).
VIA-negative
VIA negative. The button-
like, acetowhite area with
ill-defined margins is due to
a Nabothian cyst. Other ill-
defined acetowhite areas
are due to squamous
metaplasia.
(Program for Appropriate
Technology in Health
(PATH). Seattle, WA: PATH.)
 VIA-negative

The nabothian cysts appear as There is dot-like

pimple- or button-like areas after acetowhitening in the columnar
the application of acetic acid. epithelium in the anterior lip.
The squamocolumnar junction
is fully visible.
 VIA-negative
There is an ill-defined pinkish-white hue with indefinite
margins blending with the rest of the epithelium. The
squamocolumnar junction is fully visible.
VIA-negative
 VIA-negative

• There is dense, thick, mucus on the cervix before the application of acetic acid. After the application
of acetic acid, the mucus is cleared and the squamocolumnar junction becomes prominent.
 Inflammation of the cervix - cervicitis

Common agents: Trichomonas, Candida albicans, anaerobes

(Gardnerella vaginalis, G. mobilluncus and peptostreptococcus) Neisseria
gonorrhea, Chlamydia trachomatis, Escherichia coli, streptococci,
staphylococci, herpes simplex

Columnar epithelium is more prone to infection than

squamous epithelium.
Pay attention to symptoms: excessive discharge, itching of
the vulva and vagina, pain and a burning sensation during sexual
intercourse and lower abdominal pain
 Visual inspection-cervicitis
Candidial: vulvar edema and erythema, excoriation, and thick,
curdy-white, non-odorous discharge.
Non-candidial: vulval erythema and edema, reddish, tender
cervix with malodorous, greenish yellow or greyish-white
mucopurulent discharge, with or without ulceration.
Gonococcal: painful urethral discharge is also observed.
Herpes infection: vesicles and ulcers in the external
genitalia, vagina and the cervix, as well as cervical tenderness.
VIA-negative
The cervix is unhealthy, inflamed
with ulceration, necrosis,
bleeding and inflammatory
exudate.There is ill-defined,
diffuse, pinkish-white
acetowhitening with indefinite
margins blending with the rest of
epithelium (arrows).
 VIA-Positive
Pay attention to:
Sharp, distinct, well-defined, dense (opaque/dull
or oyster white) acetowhite areas, with or
without raised margins, close to the
squamocolumnar junction.
 Other conditions
• Condylomata found on the cervix, and
occasionally in the vagina and on the vulva,
associated with HPV types 6 and 11. Condylomata
are usually obvious to the naked eye (before the
application of acetic acid).
 Other conditions
• Leukoplakia (hyperkeratosis) is a well demarcated white area on
the cervix (before the application of acetic acid), due to keratosis, visible
to the naked eye. Usually leukoplakia is idiopathic, but it may also be
caused by chronic foreign body irritation, HPV infection, or squamous
neoplasia.
VIA-Positive
moderately opaque,
sharply bordered, wide
band of acetowhite
staining around the
cervical os, touching the
squamocolumnar
junction. There is mild
acetowhite staining of
the immature
metaplastic epithelium
extending onto the
endocervical polyp.
(Program for Appropriate
Technology in Health
(PATH). Seattle, WA:
PATH.)
 VIA-positive
There is a well-defined, opaque acetowhite area,
with irregular digitating margins, in the anterior
and posterior lips abutting the squamocolumnar
junction and extending into the cervical canal.
There is a well-defined, opaque acetowhite area,
with bleeding on touch, in the anterior lip, abutting
the squamocolumnar junction, which is fully visible.
VIA-positive
 VIA-positive
There is a well-defined, opaque acetowhite area,
with regular margins, in the anterior lip, abutting
the squamocolumnar junction, which is fully
visible. Note the satellite lesions in the lower lip.
There is a well-defined, opaque acetowhite area,
with regular margins, in the anterior lip, abutting the
squamocolumnar junction, which is fully visible.
Note the somewhat ill-defined white area in the
lower lip. The lesion is extending into the cervical
canal.
VIA-positive
 VIA-positive
There is a well-defined, dull, dense, There is an acetowhite area in the
opaque acetowhite area in the posterior columnar epithelium in the anterior and
lip extending into the endocervical canal. posterior lips.
 VIA-positive
There is a dense acetowhite area all over
the cervix involving all the four quadrants
and extending into the cervical canal.
Invasive cancer
Early lesions may present as a
rough, reddish, granular area that
bleeds on touch
 Invasive cancer
There is a dull, opaque, dense acetowhite
area, with raised and rolled-out margins,
irregular surface and bleeding on touch in
the posterior lip. The lesion is extending There is a proliferative growth with
into the cervical canal. The bleeding
dense acetowhitening and bleeding
obliterates acetowhitening.
 Invasive cancer

There is a dense acetowhite area with There is an ulceroproliferative growth

irregular surface contour. with acetowhitening and bleeding
Invasive cancer
More advanced cancers may
present as a proliferating,
bulging, mushroom- or
cauliflower-like growth with
bleeding and foul-smelling
discharge
 Simpulan

 Teknik pemeriksaan IVA sangat sederhana

dengan sensitibitas dan spesivisitas yang cukup
baik.
 Interpretasi IVA membutuhkan pengetahuan
tentang anatomi, histologi, dan fisiologi serviks

 IVA dapat diterapkan sebagai alat skrining

kanker serviks secara luas di Indonesia