Hemostasis following cervical punch biopsy using Monsel's solution

Hemostasis is of utmost concern after cervical punch biopsy, especially in an outpatient setting. Ferric subsulfate (Monsel's solution, Mallinckrodt Baker, Inc., USA) is widely used to achieve this task. Monsel's solution is a topical agent with excellent styptic effect, resulting from the breaking down of ferric ions and the agglutination of protein causing the small blood vessel to seal. Because of its styptic property, it is frequently used in cervical, dermatological and dental procedures [1], [2]. From the literature, the published reports on Monsel's solution concentrated mainly on hemostasis, wound healing and the possible histologic nuisance [3]. Patients' concerns on the application of this chemical after cervical punch biopsy have never been addressed. In this study, problems from the patients' perspective were investigated. This study was approved by the Institutional Review Board. One hundred women were studied over a period of 3 months. Women in whom Monsel's solution was applied for hemostasis following cervical punch biopsy were recruited. Cervical biopsies were taken using Tischler–Kevorkian biopsy forceps with 3 mm×9.5 mm cup. Monsel's solution was applied to the biopsy sites with cotton-tip applicators in paste form. Pressure was applied if necessary in order to achieve complete hemostasis. The estimated blood loss during the procedure and the number of biopsies taken were recorded. A telephone survey was conducted by a Nurse Specialist 2 weeks after the procedure. The duration and amount of vaginal bleeding (excluding menstrual bleeding), severity and nature of pain experienced, as well as other significant events were documented. Vaginal pain was divided into deep (in the pelvis) and superficial (at the perineal region). Spearman's rho correlation coefficient and Mann–Whitney U test were used for statistical analysis. Ninety-six women completed the survey. The mean age was 39.4 (19–73) and 12 women were menopausal. The median parity was 2 (0–7). A median number of 2 (1–4) cervical biopsies were taken. Twelve women had high grade cervical intraepithelial neoplasia and 84 had less severe cervical pathologies. The estimated blood loss during cervical biopsy and the results of the survey were summarized in Table 1. The severity and duration of vaginal bleeding were not associated with the women's menopausal status, number of biopsies taken, cervical histology or the estimated blood loss during cervical biopsy. Four of the nine patients who complained of superficial pain volunteered that the pain was accompanied with the drainage of Monsel's solution and their clothes were badly stained. The number of biopsies, blood loss, extent of cervical dysplasia and parity were compared between the 4 patients and the others. No significant difference between the 2 groups was detected. Positive correlation was found between lower parity and deep vaginal/pelvic pain (seven were nulliparous, four were para 1, five were para 2 and two were para 3) but not superficial vaginal pain (Mann–Whitney U test, P<0.05). From this study, 95% of the women had blood loss less than 10 ml after cervical biopsy. It suggested that Monsel's solution could achieve very good initial hemostasis. Although the extent of vaginal bleeding as assessed subjectively by most of the women was small or moderate, one-third of the women did complain of vaginal bleeding for more than a week and it did cause some concern. It has been reported that 35% of the skin wounds did not heal completely in 4 weeks after a punch biopsy if Monsel's solution was used for hemostasis [4]. However, the relationship between this delayed healing and prolonged vaginal bleeding has to be clarified. Deep vaginal/pelvic pain in women could be explained by the colposcopy procedures, which was less well tolerated in nullipara or women with lower parity. Four of 96 patients had superficial vaginal pain which they felt was due to leakage of Monsel's solution externally. It is well known that Monsel's solution is a skin irritant and can cause vaginal coagulation necrosis [5]. Therefore, minimum amount of Monsel's solution should be used. Before colposcopy examination, the patients should be informed of what they may encounter after cervical biopsy. Removal of Monsel's staining using diluted hydrochloric acid found in everyday household cleaners is an important piece of information to be included in the patient information sheet [6].