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

Proper Procedure for Performing a Pap Test

The proper procedure for performing a Pap test requires using a combination of extended tip spatula and endocervical brush, with the spatula used first to sample the ectocervix followed by the endocervical brush to sample the endocervical canal, with immediate fixation of the samples to prevent air drying. 1

Preparation and Patient Positioning

• Ensure the patient is not menstruating as this may interfere with test results
• Have the patient empty her bladder before the procedure
• Position the patient in the dorsal lithotomy position
• Select an appropriately sized speculum (may be warmed with water, but avoid lubricants as they can interfere with cytology)

Collection Materials

• Extended tip spatula for ectocervical sampling
• Endocervical brush for endocervical canal sampling
• Alternative: cervical broom device (though evidence shows the spatula-brush combination is superior) 2
• Fixative solution (95% ethanol) or spray fixative
• Glass slides (for conventional Pap) or liquid-based cytology vial

Step-by-Step Procedure

1. Insert and position the speculum:

   • Gently insert the speculum and adjust to visualize the cervix
   • If mucopurulent discharge is present, carefully remove it with a saline-soaked cotton swab before proceeding 3

2. Collect the ectocervical sample:

   • Use the extended tip spatula first
   • Place the longer projection of the spatula in the cervical os
   • Rotate the spatula in a full 360-degree circle while maintaining contact with the cervix
   • This ensures sampling of the transformation zone where most abnormal cells develop

3. Collect the endocervical sample:

   • Insert the endocervical brush into the cervical os
   • Rotate gently 90-180 degrees (not a full rotation to avoid bleeding)
   • This collects cells from the endocervical canal

4. Prepare the sample:

   • For conventional Pap: Immediately spread the material from both devices onto a properly labeled glass slide and fix immediately with spray fixative or by immersing in 95% ethanol
   • For liquid-based cytology: Rinse both collection devices in the preservation solution according to manufacturer's instructions

5. Complete the procedure:

   • Gently remove the speculum
   • Inform the patient that light spotting may occur, especially when using a cytobrush 1
   • Offer pads or tampons if needed

Special Considerations

For Pregnant Women

• Use a swab and Ayre's spatula
• Cytobrushes are not recommended during pregnancy 3, 1

For Postmenopausal Women

• An atrophic vagina may make collection challenging
• Gently scrape the cervix in a circular fashion with a wooden or plastic spatula
• An endocervical brush may be inserted and gently rotated 3
• If the vagina is too small for a speculum, some experts suggest blind swabbing or vaginal aspiration, though this is of unproven value 3

For HIV-Positive Women

• Perform cervical cytology screening twice (every 6 months) within the first year after initial HIV diagnosis
• If both tests are normal, resume annual screening 3, 1

For Women with Hysterectomy

• Women who have had a hysterectomy do not require routine Pap tests unless the hysterectomy was performed due to cervical cancer or its precursor lesions 3, 1

Common Pitfalls and How to Avoid Them

1. Inadequate sampling of the transformation zone:

   • Ensure proper visualization of the cervix
   • Use appropriate collection devices (spatula + brush combination has been shown to be superior to the broom alone) 2

2. Improper fixation:

   • Fix specimens immediately to prevent air drying which can distort cellular morphology
   • For conventional Pap smears, fix within 10 seconds of collection

3. Presence of blood or excessive mucus:

   • Gently remove mucus with a saline-soaked cotton swab before collection 3
   • Avoid scheduling during menstruation

4. Documentation errors:

   • Clearly document whether the Pap test was obtained during the visit
   • Document results, follow-up appointments, and results of follow-up appointments in the clinic record 1

5. Poor technique leading to unsatisfactory samples:

   • Basic retraining on Pap test collection and simple quality assurance measures improve the likelihood of obtaining satisfactory test results 3, 1

By following these steps carefully, clinicians can ensure high-quality Pap test specimens that maximize the detection of cervical abnormalities while minimizing patient discomfort.