Priority Topic: Gender Specific Issues & Procedure: Pap Smear

Key Feature 4: Establish office policies and practices to ensure patient comfort and choice, especially with sensitive examinations (ex: positioning for Pap, chaperones for genital/rectal exams).
Skill: Professionalism
Phase: Physical

Although many people think this test is synonymous with STI testing, it is completely not the same thing; the Papanicolaou (aka Pap) test examines purely for cervical cancer. Guidelines have been changing almost every other year it seems like. At the time of writing this blog, the Canadian national screening consensus is to begin Pap screening at the age of 25 (sooner if the patient has risk factors) and to screen every 3 years until the age of 69. There's no absolute contraindication to every doing this test per se, though the results may not be as accurate if there is current infection of the vaginitis, cervix, or pelvic inflammatory disease (so is in fact ideally NOT done when there is suspicion for an STI), or if the woman is menstruating. Not that if the bleeding is not a regular menstrual bleed but rather abnormal vaginal bleeding, obtaining a Pap would be important as a diagnostic as opposed to screening tool and would thus be indicated for that purpose.

Equipment

1. Examination table appropriate for placing the patient in the lithotomy position, in a warm, well-lit examination room.
2. Various-sized speculums
3. Water-soluble lubricant
4. Nonsterile examination gloves.
5. Large swabs for gentle blotting of excess discharge.
6. Method for warming the speculum (warm water or speculum drawer warmer [light bulb]).
7. Wooden spatulas or plastic spatulas for ectocervical sample. Cytobrush for endocervical sample. As an alternative to taking two samples, a "broom" device can be used for ectodermal and endocervical samples 
8. Microscope slides, fixative (consult with reference laboratory performing cytology for their preference) or media for liquid-based testing. Materials and solutions for liquid-based Pap smears.
9. Appropriate patient identification, history forms to accompany Pap smear and other tests.
10. Culture or transport media and swabs as necessary for gonorrhea, chlamydia, herpes, fungal, and potassium hydroxide (KOH)/wet mount. (Although the Pap test does not test for STIs, this does not mean that the clinician cannot screen or sample discharge to look for evidence of an STI when performing a Pap).
11. Cervical tenaculum or cervical hook (rarely needed).
12. Ring forceps.

Anatomy of a cervix

1. The cervix is the distal portion of the uterus, and the external opening on the cervix is the external os. 
2. The area of the squamocolumnar junction marks the transition from the squamous epithelium of the exterior cervix to the columnar epithelium of the endocervical canal. The area is also called the transformation zone and it's where we want to sample the cells of the cervix for evidence of malignant transformation (this is the are where cancer arises when it does). 
3. In women who have had a hysterectomy for concerns of malignancy, the cervix is gone (because the whole uterus has been removed) and we sample cells from the blind pouch at the top in case there have been some cervical cells left behind.

Procedure

1. Obtain consent and offer chaperone
2. Ideally plan to perform the procedure in the middle of a patient's cycle. Prior to performing the patient, the patient may wish to void urine. She should have her bottoms off but be draped until the procedure is done.
3. Prepare equipment. Label sample holders (glass slide or liquid Pap vial, depending on the type of Pap equipment being used). 
4. Position patient in the lithotomy position with feet in stirrups.
5. Don a pear of gloves that do not need to be sterile. It is a clean but not a sterile procedure.
6. Begin the procedure, placing a small amount of water-soluble lubricant on the speculum prior to insertion (see this post where I explain the steps of a speculum exam for details). Make sure to identify the cervical landmarks, including the transformation zone with its squamocolumnar junction. This will increase the likelihood of getting a good quality sample.
7. Document the procedure.
8. Followup with the results of the testing and proceed to further investigations or else repeat the Pap screening test in approximately 3 years, in keeping with national cervical cancer screening guidelines.