What is the proper procedure for performing a Pap (Papanicolaou) test?

Proper Procedure for Performing a Pap Test

The proper procedure for a Pap test requires using either a cervical broom rotated five complete times in one direction or a combination of extended tip spatula and endocervical brush to collect adequate cervical samples, followed by immediate fixation or placement in liquid preservative. 1

Preparation and Patient Considerations

• Avoid collecting Pap tests during menstruation; postpone and reschedule at the earliest opportunity 1
• Presence of mucopurulent discharge should not delay the Pap test; remove discharge with a saline-soaked cotton swab before collection 1, 2
• For pregnant women, use a swab and Ayre's spatula; cytobrushes are not recommended during pregnancy 1

Collection Devices and Techniques

Option 1: Cervical Broom Method

1. Insert the long central bristles of the broom into the endocervical os
2. Press the broom against the cervix so the outer bristles bend
3. Rotate the broom in one direction (clockwise) for five complete rotations 1
   • Note: Rotating in one direction then the other is not recommended as it can result in cell loss
   • Research suggests that 1800° rotation (five full turns) maximizes endocervical cell collection and detection of abnormal cells 3

Option 2: Extended Tip Spatula and Endocervical Brush Method

1. Recommended sequence: Use the spatula first, followed by the endocervical brush
   • This sequence results in fewer blood-obscured specimens and potentially better detection of squamous intraepithelial lesions 4
2. Use the extended tip spatula to sample the ectocervix (360° rotation)
3. Use the endocervical brush to sample the endocervical canal 1
   • Insert the brush into the endocervical canal
   • Rotate gently to collect cells

Sample Processing

For Conventional Cytology:

1. For cervical broom: Stroke the broom on a glass slide from the label margin toward the other end 1
2. For spatula and brush: Roll the endocervical brush onto the slide near the frosted label area, then smear the spatula sample adjacent to it 1
3. Immediately fix the sample with spray fixative or immerse in 95% ethanol to prevent air drying 1

For Liquid-Based Cytology (Preferred Method):

1. Rinse the collection device(s) in preservative solution
   • Some manufacturers recommend rinsing devices thoroughly
   • Others recommend snapping off the handle and leaving the device in the fixative 1
2. Label the container with the patient's name 1
3. Liquid-based cytology is preferred as it produces fewer inadequate readings and false-negative results 1

Post-Collection Considerations

• Warn patients about the possibility of light bleeding or spotting after the test, especially when using a cytobrush 1
• Offer tampons or pads for any bleeding after the examination 1
• Discuss findings and recommendations with the patient after she is dressed 1

Special Populations

• HIV-positive women: Should receive cervical cytology screening twice (every 6 months) within the first year after initial HIV diagnosis; if both tests are normal, annual screening can be resumed 1
• Women with hysterectomy: Do not require routine Pap tests unless the hysterectomy was performed due to cervical cancer or precursor lesions 1

Quality Assurance Tips

• The combination of cytobrush (for endocervix) and spatula (for ectocervix) is superior for obtaining quality Pap smears compared to using the broom alone 5
• Health-care providers who receive basic retraining on Pap test collection and clinics that use simple quality assurance measures are more likely to obtain satisfactory test results 1
• Document Pap test results, follow-up appointments, and results of follow-up appointments clearly in the clinic record 1

By following these evidence-based procedures, clinicians can maximize the detection of cervical abnormalities while minimizing inadequate samples, ultimately improving patient outcomes through early detection of cervical neoplasia and cancer.