Experience With Flexible Vaginoscopy, Insights From an Ongoing Quality Improvement Project

Abstract

Vaginoscopy is a common procedure performed on prepubescent girls. It is considered a standard diagnostic procedure most often preformed in the operating suite under sedation or anesthesia. New technology now allows gynecologists to perform vaginoscopy in the office as easily as in the operating room. As a quality improvement project we evaluated the percentage of operating room vaginoscopy. Our goal is to decrease operating room vaginoscopy to 15%. With approval for a quality improvement project by our metropolitan, tertiary care children’s hospital, we proceeded to collect information for all patients undergoing vaginoscopy including both under anesthesia and in the office setting. We collected the indication for procedure, whether or not a child-life specialist was present, time of device within vagina, whether the procedure was successful, whether the patient subsequently went to the operating room and the pain analog scale post procedure if awake. Descriptive statistics were used to analyze the data. Twenty five total procedures have been performed over a six month time course including in the office setting, operating room setting, emergency room setting as well as awake and with sedation. Thirteen total procedures were performed in the office setting without sedation. Five procedures were performed under anesthesia in operating room without attempt in the office setting. Four procedures were repeated in the operating room for all reasons, including inability to tolerate in office (2), equipment malfunction (1), and need for biopsy (1). Average age of patient who completed the procedure awake was 8y10m. Average time of procedure (device within vagina) was 5minutes with the range of 1-12 minutes. Average visual analog pain scale of awake patients was 3.6 with a range of 0-10. Percentage of operating room vaginoscopy is 37.5% in the first three months of use. In the next three months of use, the percent was 37.5% performed in operating room under general anesthesia and 18.8% under conscious sedation in emergency room or interventional radiology suite. Our experience demonstrates that the in-office vaginoscopy using hand held endoscopy device is an excellent choice for certain patients. Appropriate counseling and preparation of patients and guardian is essential. Of the 25 procedures, 21 of the procedures were successful in the setting we attempted first. Four procedures were repeated in the operating room setting. Five procedures were performed with the primary setting in the operating room. Thirteen procedures were performed with the primary setting in the office or emergency room. All patients selected were successfully completed in the ambulatory setting and none were placed in observation or admitted after the procedure. Our data also supports the importance of patient selection and key nature distraction plays in success of the procedure. Our project is ongoing and cites a trend towards decreased necessity for vaginoscopies in the operating room as we investigate other avenues to decrease our operating room vaginoscopy procedure rate toward 15%.