01. Papanicolaou (PAP) smear

Resident Editors: Lily Kornbluth, M.D.

Faculty Editor: Michelle Guy, M.D.

Indications

  • Refer to Cervical Cancer Screening section

Relative Contraindications

The following can potentially interfere with adequate squamous cellularity, though most of the time, the test will be satisfactory for evaluation:

  • Active menstruation (particularly days 1-2 when bleeding is heaviest)
  • Douching, sexual intercourse, spermicide or tampon use within 48 hours

Materials needed

  • Cytology Method:
    • ThinPrep (has the benefit of being able to use same sample for HPV testing)
    • SurePath
    • Conventional Smear -> slides + fixation solution (need separate sample for HPV testing)
  • Collecting instruments: spatula, cytobrush
  • Speculum
  • Lubricant -- approved lubricants include Surgilube®, Astroglide®, and Crystelle®, as they do not contain carbomers
  • Examination light
  • Large cotton-tip swabs
  • Specimen bag
  • Patient labels
  • Cytology form/orders
  • Swabs for GC/Chlamydia testing, if indicated
  • Glass slide and smaller cotton-tip swabs for wet mount, if indicated
  • Normal saline and KOH for wet mount, if indicated

Technique

  • Discuss whether patient has had past difficulties with pap smears or speculum exams.
  • Arrange all materials on tray ahead of time to facilitate a smooth exam.
    • e.g. uncap ThinPrep, remove speculum from plastic bag
  • Position patient properly
    • Help patient into stirrups
    • Make sure patient’s buttocks are flush with the end of the exam table
    • Make sure patient is as comfortable as possible. The more relaxed she is, the more easily you will be able to find her cervix
    • Ensure the patient will not be exposed should someone enter the room (e.g., pull the curtain)
  • Place speculum in the vaginal vault.
    • Start with the smallest speculum first and move to a larger size if necessary.
    • Use warm tap water or, if necessary, (for patients with atrophy) a thin layer of approved lubricant on the posterior blade of the speculum, avoiding the tip.
    • Separate the labia with one hand and move any hairs. With the opposite hand slowly insert speculum.
    • Exert primarily downward pressure while moving the speculum to the posterior-inferior corner of the vaginal vault. Insert completely.
    • Open and adjust the speculum until the cervix is visualized completely.
  • If there is copious vaginal discharge: blot with large cotton swab (do not rub). Avoid touching the cervical os directly as this may remove the upper thin layer of cells needed for adequate exam.
  • Pap testing should be done before other swabs or cultures are taken.
  • Pap testing: Sample both ectocervical and endocervical cells:
    • To collect ectocervical cells: Use the spatula. Place one lobe of the tip in the os and gently scrape the other lobe circumferentially 360-degrees around the os. Swish the spatula tip in the liquid medium to transfer the sample (liquid-based) OR place the sample on a slide (conventional).
    • To collect endocervical cells: Use the cyto-brush. Place the head of the brush completely into the os and rotate 180-degrees. For liquid-based cytology: swish the brush tip in the solution (you may be able to break off the tip of the brush into the solution). For conventional Pap: place the sample on a separate slide.
    • For samples placed on slides: apply or immerse in fixation solution immediately
  • Wet Mount (if indicated): Refer to Vaginal Wet Mount section
  • GC/Chlamydia testing (if indicated):
    • For GC: swab ectocervix
    • For Chlamydia: swab ecto- and endo-cervix
  • Make sure that a patient label is placed on each specimen/slide collected.
  • Complete Cytology order form.  Indicate LMP and any abnormalities found on exam such as friable cervix, bleeding from os, stenosis of os, vaginal discharge, etc.

References

ThinPrep® Pap Test Quick Reference Guide.  www.thinprep.com/pdfs/pap_quick_reference.pdf.  Accessed June 24, 2014.