If a cervical mass is visualized during a speculum examination, should a Pap smear be performed or should the patient be referred to a gynecologist (GYN) or gynecologic oncologist?

Management of Visualized Cervical Mass on Speculum Examination

When you visualize a cervical mass during speculum examination, skip the Pap smear and refer directly to a gynecologic oncologist for colposcopy and biopsy. A Pap smear is a screening tool for microscopic cellular abnormalities, not a diagnostic test for grossly visible lesions.

Why Pap Smear is Inappropriate for Visible Masses

• Pap smears are designed to detect pre-cancerous cellular changes in apparently normal-appearing cervices, not to diagnose visible masses 1
• A visible cervical mass represents a clinical diagnosis that requires tissue biopsy for definitive pathologic evaluation, not cytologic screening 1
• Performing a Pap smear on a visible mass delays appropriate diagnosis and treatment while providing no useful diagnostic information 2

Immediate Referral Pathway

• Refer directly to a gynecologic oncologist or specialist capable of performing colposcopy with directed biopsy 1, 2
• The referral should be urgent/prompt, as visible cervical masses may represent invasive cancer requiring staging and treatment planning 1, 2
• Document the appearance, size, and characteristics of the mass in your referral 1

What the Specialist Will Do

• Colposcopic examination with directed cervical biopsy is the standard diagnostic approach 1
• Endocervical curettage (ECC) may be performed to evaluate the endocervical canal 1
• If adenocarcinoma or adenocarcinoma in situ (AIS) is suspected, cold knife conization (CKC) may be necessary for complete evaluation 1
• Imaging studies (MRI, CT, or PET) may be ordered to assess disease extent if malignancy is confirmed 2, 3

Common Pitfall to Avoid

• Do not delay referral by obtaining a Pap smear first - this is the most critical error in management 2
• The presence of a visible mass supersedes routine screening protocols and requires immediate tissue diagnosis 1, 2
• Even if the patient is due for routine screening, the visible mass takes diagnostic priority and requires different evaluation 1

Clinical Context

• While most cervical masses may be benign (such as polyps or nabothian cysts), the differential diagnosis includes invasive cervical cancer, which requires prompt specialist evaluation 2, 4
• The goal is to exclude malignancy through histologic examination, not cytologic screening 1, 2