What are the steps of a Pap (Papanicolau)/pelvic exam?

Steps of a Pap/Pelvic Examination

A complete pelvic examination consists of external genital inspection, speculum examination, collection of specimens (including Pap test when indicated), and bimanual examination. 1

Patient Preparation

• Explain the procedure in detail before starting
• Allow patient to empty bladder before examination
• Offer presence of a companion if preferred
• Reassure patient that nothing will be done without informing her first
• Position patient in dorsal lithotomy position

Step 1: External Genital Examination

• Inspect external genitalia for:
  • Signs of inflammation
  • Changes in pigmentation
  • Lesions (e.g., Bartholin gland abscess, genital ulcers, warts)
  • Clitoris size (width should be <10 mm)
  • Pubic hair distribution
  • Hymen patency and configuration

Step 2: Speculum Examination

• Select appropriate size speculum
• Apply water-based lubricant if not collecting specimens for cytology
• Insert speculum at oblique angle, then rotate to horizontal position
• Open speculum blades to visualize cervix
• Inspect:
  • Vaginal walls for lesions, discharge, inflammation
  • Cervix for color, appearance, secretions, lesions, polyps, or masses

Step 3: Specimen Collection (when indicated)

• Pap test collection (first Pap test should be performed at age 21, not at onset of sexual activity) 1, 2:

  • Use Papanicolaou paddle rotated 360° to sample entire exocervix
  • Use cytobrush to collect endocervical specimen
  • For liquid-based Pap tests (preferred due to fewer inadequate readings):
    • Transfer collected cells to liquid medium
    • Warn patient about possible light bleeding after the procedure
  • For conventional Pap tests:
    • Smear specimen directly on slide
    • Fix immediately before air drying

• Other specimen collection (when indicated):

  • For wet prep/potassium hydroxide examination:
    • Collect vaginal secretions with cotton swab
    • Place in tube with normal saline or directly on slide
  • For vaginal pH testing:
    • Dip pH paper in secretions on speculum tip after removal
    • Read color change within 10 seconds (normal pH <4.5)

Step 4: Bimanual Examination

• Insert 1-2 lubricated, gloved fingers into vagina
• Assess cervix:
  • Consistency (firm in non-pregnant state, softer in pregnancy)
  • Cervical motion tenderness (indicates pelvic infection/inflammation)
• Palpate uterus:
  • Size and tenderness
  • Position and mobility
• Examine adnexa (ovaries):
  • Pain or masses
  • Normal ovaries are barely palpable

Step 5: Post-Examination

• Allow patient time to remove excess lubricant
• Offer tampons or pads for any bleeding
• Discuss findings and recommendations once patient is dressed

Important Considerations

• Liquid-based Pap tests are preferred over conventional methods due to fewer inadequate readings and false-negative results 1
• The cytobrush can cause bleeding, particularly in patients with STIs
• Approximately 30% of women report pain, discomfort, fear, or anxiety during examination 2
• Distinguishing between discomfort and true pain can be challenging, especially in adolescents 1
• Routine screening pelvic examinations are not recommended for asymptomatic women 2

Common Pitfalls to Avoid

1. Failing to adequately explain the procedure before starting
2. Not allowing patient to have control over the examination process
3. Confusing cervical motion tenderness with normal discomfort during examination
4. Performing unnecessary pelvic examinations in asymptomatic women
5. Assuming a pelvic examination is required before prescribing hormonal contraceptives
6. Mistaking that a patient has had a Pap test when only a pelvic examination was performed

By following these steps systematically while maintaining patient comfort and dignity, providers can perform thorough and appropriate pelvic examinations when clinically indicated.