What are the steps for performing a pelvic exam and Pap (Papanicolaou) test?

Steps for Performing a Pelvic Exam and Pap Test

The pelvic examination should begin with patient preparation and education, followed by systematic external inspection, speculum insertion for cervical visualization and Pap collection, and conclude with bimanual examination to assess internal pelvic structures. 1

Pre-Examination Preparation

• Have the patient empty her bladder before the examination to minimize discomfort during bimanual palpation 1
• Explain each step before performing it, emphasizing that the examination may be uncomfortable but should not be painful in the absence of pathology 1
• Reassure the patient she can say "wait," "stop," or "that's not comfortable" at any time—she maintains control of her body 1
• Allow 10-15 minutes for the examination, particularly if it is the patient's first examination or if she has had previous negative experiences 1
• If the patient is not tolerating the examination, stop and reschedule to avoid creating negative associations 1

Equipment Setup

Required items include: examination table with stirrups, adequate adjustable light source, non-latex gloves, water-based lubricant, vaginal specula of various sizes, Pap collection devices (cytobrush and spatula or broom device), liquid-based cytology vial or glass slides with fixative, cotton swabs, and materials for wet mount preparation if indicated 1

External Genitalia Examination

• Inspect pubic hair and note Tanner stage (sexual maturity rating) 1
• Look for lesions including pubic lice, nits, folliculitis, hidradenitis suppurativa, genital warts (condyloma acuminata), ulcers, or molluscum contagiosum 1
• Assess for signs of inflammation (redness, swelling), pigmentary changes (hypopigmentation from lichen sclerosus or vitiligo) 1
• Retract the clitoral hood and evaluate clitoral size (width should be <10 mm; enlargement suggests elevated androgens) 1
• Examine the hymen for patency and configuration, noting imperforate, microperforate, cribriform hymen, or hymenal bands that may impair menstrual flow 1
• Inspect the vulva, perineum, and anus for any abnormalities 2

Speculum Examination

• Select an appropriately sized speculum based on patient age, sexual history, and body habitus; smaller specula reduce discomfort in adolescents and nulliparous women 3
• Apply water-based lubricant to the speculum to ease insertion and minimize discomfort 3
• Insert the speculum with the blades oriented obliquely initially, then rotate to horizontal position as you advance 1
• Open the speculum gently until the cervix is visualized 1
• If the cervix cannot be visualized in standard dorsal lithotomy position in patients with severe obesity, consider using the lateral decubitus position with the patient lying on her side, knees bent, with an assistant elevating the upper leg 45 degrees 4

Cervical Cytology Collection (Pap Test)

• For conventional cytology, ideally schedule the test 10-20 days after the first day of menses; liquid-based cytology can be performed at any time during the menstrual cycle 1
• If mucopurulent discharge is present, remove it with a saline-soaked cotton swab before collecting the specimen—do not postpone cytology testing 1
• For liquid-based Pap tests (preferred method): Use a broom device or spatula plus cytobrush to sample the ectocervix and endocervix, then rinse the collection device in the liquid-based cytology vial 1
• For conventional Pap tests: Rotate a Papanicolaou paddle 360° to sample the entire exocervix, then use a cytobrush for the endocervical specimen 1
• Use instruments designed to sample the cervical transformation zone (cytobrushes) as they improve cytology test accuracy 1
• Fix conventional slides immediately before air drying 1
• Warn the patient about possible light bleeding or spotting after the Pap test, particularly when using the cytobrush, as bleeding may be more prominent in patients with STIs 1

Additional Specimen Collection (If Indicated)

• Collect vaginal specimens for STI testing before or after the Pap test—the sequence does not influence Pap test results 1
• For wet mount preparation: Use a cotton swab to collect vaginal secretions, place in a tube with 1 mL normal saline, then prepare a glass slide for microscopic examination 1
• Look for white blood cells (infection), clue cells (bacterial vaginosis), trichomonads, and yeast on wet mount 1
• Measure vaginal pH using pH paper dipped in secretions from the speculum tip (normal pH <4.5; elevated with bacterial vaginosis and trichomoniasis) 1
• Perform whiff test by mixing vaginal secretions with potassium hydroxide—a fishy odor indicates bacterial vaginosis 1

Bimanual Examination

• Remove the speculum and insert one or two lubricated gloved fingers into the vagina 1
• Assess cervical consistency: the normal non-pregnant cervix is firm, while a gravid cervix is softer 1
• Gently move the cervix to assess for cervical motion tenderness, which indicates pelvic infection or inflammation; distinguish true pain from pressure/discomfort, particularly in adolescents 1
• Palpate the uterus for size, position, and tenderness using the other hand on the abdomen 1
• Assess the adnexa (ovaries) for masses or tenderness; normal ovaries are usually barely palpable 1

Post-Examination Care

• Allow the patient time to remove excess lubricant 1
• Offer tampons or pads for any bleeding 1
• Discuss findings and recommendations once the patient is dressed 1

Critical Timing and Screening Guidelines

• Begin cervical cancer screening at age 21, regardless of age at first sexual intercourse 5
• For women 21-29 years: Screen every 3 years with cytology alone 5
• For women 30-65 years: Preferred approach is cytology plus HPV co-testing every 5 years, or cytology alone every 3 years as an acceptable alternative 5
• Stop screening at age 65 if the patient has had 3 consecutive negative cytology results or 2 consecutive negative co-test results within 10 years, with the most recent test within 5 years 5

Common Pitfalls to Avoid

• Do not confuse pelvic examination with Pap testing—many women erroneously believe they had a Pap smear when only a pelvic exam was performed 5
• Cytology and HPV tests are not screening tests for STIs 1
• Do not use vague terminology like "normal cervix" or "benign findings" in documentation—use standardized Bethesda terminology with "NILM" (negative for intraepithelial lesion or malignancy) for normal results 6
• Document specimen adequacy, noting whether the specimen is "satisfactory for evaluation" and specifically noting presence or absence of endocervical/transformation zone component 6