From the Guidelines
The best technique for a pelvic exam and Pap smear involves using a liquid-based cervical cytology or a conventional Papanicolaou (Pap) smear, with the addition of HPV co-testing for patients over 30, as recommended by the American Cancer Society in 2020 1. To perform the exam, begin by having the patient in the lithotomy position with proper draping for comfort and dignity.
- First, perform an external genital examination,
- then insert a warmed, lubricated speculum at a 45-degree angle, rotating it to horizontal once past the introitus.
- Gently open the speculum to visualize the cervix. For the Pap smear,
- use a cervical brush to collect cells from the transformation zone by inserting it into the cervical os and rotating it 360 degrees 3-5 times.
- For patients over 30, collect a sample for HPV co-testing, as primary HPV testing is a useful adjunct to cervical cytology screening in select patients 1.
- Transfer the collected cells immediately to preservative solution or slide. After removing the speculum,
- perform a bimanual examination to assess the uterus and adnexa. Throughout the procedure,
- communicate clearly with the patient, explaining each step and checking for comfort. This technique maximizes sample adequacy while minimizing patient discomfort, as the transformation zone is targeted because it's where most cervical abnormalities develop, making proper sampling technique crucial for accurate screening results 1. The use of liquid-based cervical cytology has advantages over conventional Pap testing, including the ability to perform HPV testing using the same sample, and it is easier to read 1. Testing that includes HPV is more sensitive than cervical cytology alone, but is less specific, highlighting the importance of proper patient selection for co-testing 1.
From the Research
Pelvic Exam Pap Smear Technique
The best technique for a pelvic exam Pap smear involves the use of specific devices and collection methods to ensure high-quality results.
- The combination of the Cytobrush for the endocervix and spatula for the ectocervix is superior for a quality Pap smear 2.
- The Cervex-brush (broom) is associated with poor quality indicators, including absent endocervical cells, limited or unsatisfactory results, and obscuring inflammation 2.
- The sequence of collection is not important in conventional Pap smears 2.
- Presence of infectious agents can contribute to the absence of endocervical cells, decreasing the quality of the Pap smear 2.
Device Selection and Collection Method
The selection of devices and collection method is crucial for a quality Pap smear.
- A variety of sampling devices are available, with the aim of augmenting sampling of the complete transformation zone (TZ) and the squamocolumnar junction (SCJ) while causing minimal trauma to the cervical and endocervical epithelium 3.
- The Cervex brush is designed to ensure sampling of the complete TZ and SCJ, and liquid-based preparations have made the process easier with pre-fixation of cells and standardized transfer of cells onto the glass slide 3.
- Immediate wet fixation of the smear is essential for reliable cervical cytology and detection of precancerous lesions 3.