Cervical Polyp Removal

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Introduction

Cervical polyps are pedunculated tumors that commonly arise from the mucosa of the endocervical canal. They are usually 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. 
 
TABLE 69-1.
Differential Diagnosis
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. 
An association exists 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 in Table 69-1
Because most polyps are benign, they may be removed or observed on routine examinations. They are often twisted off during routine examinations to reduce 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. 

Potential Equipment

  • Ring forceps

  • Cervical curette

  • Kogan’s endocervical speculum

  • Cervical biopsy forceps

  • Monsel’s solution

Indications

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

Contraindications

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

  • Severe bleeding disorders

  • Local infection

The Procedure

Step 1

Perform a standard gynecologic examination to identify the polyp and any other cervical abnormalities. 

Step 2

Attempt to identify the base of the polyp and ensure it originates from the cervical canal. 

Step 3

If the base of the polyp can not be readily identified, consider using Kogan’s endocervical speculum to move the polyp and identify the base. 
  • PEARL: When the base is identified, the endocervical speculum may be closed on the polyp and used to remove it.

Step 4

Gently grasp the polyp with ring forceps or the endocervical speculum, apply slight traction, and twist repeatedly 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.

Step 5

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. 
  • 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.

Step 6

Inspect the cervical os to make sure the entire polyp was removed. If a significant amount of the base of the polyp remains, it may be scraped off with a curette. 

Step 7

If a significant amount of bleeding is present, Monsel’s paste may be applied for hemostasis. 

Complications

  • Typically none

  • Bleeding

  • Regrowth

Pediatric Considerations

This procedure is almost never necessary or performed in the pediatric population. 

Postprocedure Instructions

After removal of a polyp, the patient should avoid sexual intercourse, douching, and tampon usage for several days. A follow-up examination may 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. 

Coding Information and Supply Sources

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. 
The medical equipment such as Ring forceps, curettes, Kogan’s endocervical speculums, and cervical biopsy forceps may be ordered from: 

Bibliography

Abramovici H, Bornstein J, Pascal B. Ambulatory removal of cervical polyps under colposcopy. Int J Gynaecol Obstet.  1984;22:47–50. [View Abstract]
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. [View Abstract]
David A, Mettler L, Semm K. The cervical polyp: a new diagnostic and therapeutic approach with CO2 hysteroscopy. Am J Obstet Gynecol.  1978;130:662–664. [View Abstract]
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.
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Khalil AM, Azar GB, Kaspar HG, et al. Giant cervical polyp: a case report. J Reprod Med.  1996;41:619–621. [View Abstract]
Lee WH, Tan KH, Lee YW. The aetiology of postmenopausal bleeding—a study of 163 consecutive cases in Singapore. Singapore Med J.  1995;36:164–168. [View Abstract]
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. [View Abstract]
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. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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