cervical speculum examination. - the hillingdon · pdf filecervical speculum examination and...

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Speculum examination

Inspection of vagina

Inspection of cervix

Cervical smear

methods

devices

Slide method

Liquid-based cytology

Swabs

Removing the speculum

Ending the procedure

Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical speculum examination Cervical speculum examination and taking a smear.and taking a smear.

Cusco

Sims

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Learning OutcomesLearning Outcomes

Able assemble the speculum Able assemble the speculum correctlycorrectlyAble to inspect vagina and cervix Able to inspect vagina and cervix using a speculumusing a speculumPerform a cervical smearPerform a cervical smear

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Speculum examinationSpeculum examination

1.1. Designed for the inspection of the Designed for the inspection of the cervix and vaginal walls.cervix and vaginal walls.

Bivalve (cusco) speculum is the instrument Bivalve (cusco) speculum is the instrument most commonly used to inspect the most commonly used to inspect the vaginavagina

2. Access to the cervix and fornices 2. Access to the cervix and fornices for bacteriological swabs and for bacteriological swabs and cervical smears.cervical smears.

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

ExaminationExamination

GRIPGRIPGreet, rapport, introduce and identify, explain Greet, rapport, introduce and identify, explain procedureprocedure

Tell the patient the procedure is not Tell the patient the procedure is not painful, but may be a bit uncomfortable.painful, but may be a bit uncomfortable.Make sure:Make sure:

not menstruatingnot menstruatingno spermicide, lubricant, sexual intercourse no spermicide, lubricant, sexual intercourse in the previous 48 hours.in the previous 48 hours.

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

PositionPosition

“Lie on the couch, put your heels together, draw them up to your bottom and let your knees flop apart”

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Speculum examinationSpeculum examinationWarm blades under a stream of tepid Warm blades under a stream of tepid water.water.Wear gloves, prepare the slide/bottleWear gloves, prepare the slide/bottleWrite name of the patient, date and time Write name of the patient, date and time of taking the specimen with of taking the specimen with pencilpencil not not pen if using pen if using slideslideHold the speculum with dominant hand, Hold the speculum with dominant hand, separate the labia and expose introitus separate the labia and expose introitus with nonwith non--dominant handdominant handTell the patient you are about to Tell the patient you are about to introduce the speculum and reassureintroduce the speculum and reassure

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Speculum examinationSpeculum examinationSlide the closed blades obliquely over Slide the closed blades obliquely over the fingers into the introitus , introduce the fingers into the introitus , introduce the instrument into the vaginathe instrument into the vagina

While inserting the instrument rotate it to While inserting the instrument rotate it to a clockwise direction until the anterior a clockwise direction until the anterior and posterior blades run along the and posterior blades run along the anterior and posterior vaginal walls with anterior and posterior vaginal walls with the handles pointing towards the anus or the handles pointing towards the anus or clitoris.clitoris.

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Speculum examinationSpeculum examination

Maintain a downward pressure, on Maintain a downward pressure, on the speculum and press on the the speculum and press on the thumb piece to hinge the blades thumb piece to hinge the blades open to expose the vaginal vault open to expose the vaginal vault and cervix.and cervix.Adjust the light source to illuminate Adjust the light source to illuminate the vagina.the vagina.Inspect vagina and cervix.Inspect vagina and cervix.

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Inspection of the vaginaInspection of the vagina

Discharge:Discharge:Normal Normal –– clear / milky, odourlessclear / milky, odourless

Increased during ovulation, pregnancy, breastIncreased during ovulation, pregnancy, breast--feeding, sexual arousalfeeding, sexual arousal

Cottage cheese / curdCottage cheese / curd--like: like: candidacandida (assoc. (assoc. with pain, itching, swelling and erythema of with pain, itching, swelling and erythema of the vulva)the vulva)Frothy, fishy odour: Frothy, fishy odour: TrichomoniasisTrichomoniasisAsymptomatic discharge: gonorrhoeaAsymptomatic discharge: gonorrhoea

UlcersUlcersForeign bodyForeign body

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Inspection of the cervixInspection of the cervix

Cervix normally points posteriorly Cervix normally points posteriorly and inferiorlyand inferiorly

Look for:Look for:DischargeDischargeCystsCystsPolypsPolypsUlceration or fungating growthUlceration or fungating growth

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Normal Normal with ectropion

cervicitis cancer

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical ScreeningNabothian cyst – mucus filled cervical cyst due to blockage of a mucus gland

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical polyp (appears to be descending through the os)

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical smearCervical smear

Cervical smear performed after Cervical smear performed after inspecting the cervix.inspecting the cervix.

The aim is to sample cells from the transformation zone (where the epithelium changes from columnar to squamous)

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical smear Cervical smear -- methodsmethods

Newer method = Newer method = LBC LBC (( LiquidLiquid––based based cytology )cytology )

Use cervex brush (see next slide)Use cervex brush (see next slide)Dip brush into bottle of liquid fixativeDip brush into bottle of liquid fixativeFewer inadequate samples. Being rolled out Fewer inadequate samples. Being rolled out across the UKacross the UK

Older method = Older method = slidesslidesUse Aylesbury spatula (see next slide)Use Aylesbury spatula (see next slide)Spray or dip in fixativeSpray or dip in fixative

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical smear Cervical smear -- devicesdevices

LBCLBCA cervex brush is A cervex brush is commonly usedcommonly used

SlideSlide--basedbasedA wooden spatula A wooden spatula is used with a bifid is used with a bifid end (Aylesbury end (Aylesbury spatula) .spatula) .

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Liquid Based Cytology methodLiquid Based Cytology method

Use a cervex brushUse a cervex brush

Place the tip of the brush in the osPlace the tip of the brush in the osTwirl 10 timesTwirl 10 timesPlace brush in fixative bottle and dip Place brush in fixative bottle and dip / stir / squish vigorously to wash the / stir / squish vigorously to wash the cells off the brush into the bottlecells off the brush into the bottle

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Slide methodSlide method

The bifid end is used to harvest the The bifid end is used to harvest the cervical cells.cervical cells.Introduce the spatula through the Introduce the spatula through the speculum and position the bifid end speculum and position the bifid end at the os.at the os.Rotate through 360Rotate through 360°°

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

The desquamating cells are The desquamating cells are collected by rotating the spatula collected by rotating the spatula around the circumference of the around the circumference of the os and the lips of the cervix.os and the lips of the cervix.

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Cervical smear

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devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening


Send sample to the labSend sample to the lab

Spread the cervical material onto the Spread the cervical material onto the labelled glass slide by stroking each labelled glass slide by stroking each side of the bifid end of the spatula side of the bifid end of the spatula along the glassalong the glass

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening


The cervical cells and some mucus The cervical cells and some mucus should cling to the glass.should cling to the glass.Immediately spray the slides with Immediately spray the slides with fixative or fix them by immersion in fixative or fix them by immersion in 95% alcohol95% alcoholDo not allow the sample to dry.Do not allow the sample to dry.

Some examples of cells processed with the Papanicolau stain

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

SwabsSwabs

If any ulcers, take swab from base of If any ulcers, take swab from base of ulcer.ulcer.

If infection suspected, take swab from If infection suspected, take swab from cervix or high vaginal.cervix or high vaginal.

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Removing the speculumRemoving the speculum

Undo the thumb screwUndo the thumb screwSimultaneously withdraw the speculum Simultaneously withdraw the speculum and rotate the open blades to ensure that and rotate the open blades to ensure that the anterior and posterior walls of vagina the anterior and posterior walls of vagina can be inspected.can be inspected.Near the introitus, allow the blades to Near the introitus, allow the blades to closecloseTaking care not to pinch the labia or any Taking care not to pinch the labia or any hairs while withdrawing the speculum. hairs while withdrawing the speculum.

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Ending the procedureEnding the procedure

Tell the patient that you have Tell the patient that you have finished , give a towel to the patient finished , give a towel to the patient to wipe herself.to wipe herself.

Send samples to labSend samples to lab

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

SummarySummaryNNecessary equipmentecessary equipment

CuscoCusco’’s speculums speculumCervix brushCervix brushSpecimen bottleSpecimen bottleMicrobiology swabsMicrobiology swabsWater based lubricantWater based lubricantTissuesTissues

IIntroduce yourselfntroduce yourselfIdentify patient (full name and DOB)Identify patient (full name and DOB)PProcedure rocedure ––

Explain what you are going to do and Explain what you are going to do and what she may experiencewhat she may experience

PermissionPermissionObtain informed consentObtain informed consent

PPrivacyrivacyPositionPosition

Heels together, draw heels towards Heels together, draw heels towards bottom, let knees flop apartbottom, let knees flop apart

LLightightEExposurexposure

Remove clothing from the waist Remove clothing from the waist down, cover with blanketdown, cover with blanket

Wash hands, don glovesWash hands, don glovesLabel bottle and open the lidLabel bottle and open the lidAssemble speculumAssemble speculumIf not in warmer, warm under tapIf not in warmer, warm under tapUse fingers to keep blades shutUse fingers to keep blades shutWarn patientWarn patientSeparate labiaSeparate labiaInsert with rotating motionInsert with rotating motionAvoid touching clitorisAvoid touching clitorisUnder direct vision open the blades Under direct vision open the blades and angle the speculum accordingly and angle the speculum accordingly so that cervix comes into viewso that cervix comes into viewInspect cervix and lateral vaginal Inspect cervix and lateral vaginal wallswallsInsert tip of cervex brush into osInsert tip of cervex brush into osRotate 10X, sample whole cervixRotate 10X, sample whole cervixRemove brush and dip vigorously into Remove brush and dip vigorously into bottlebottleRemove the speculum gently, rotate Remove the speculum gently, rotate to inspect anterior and posterior to inspect anterior and posterior vaginal wallsvaginal wallsLet the blades close carefullyLet the blades close carefullyOffer patient some tissues to wipe Offer patient some tissues to wipe herself, cover her with blanket and herself, cover her with blanket and leave the curtained arealeave the curtained area

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Further ReadingFurther Reading

Why screen regularly with smear Why screen regularly with smear testtestWhat is CIN ?What is CIN ?What are the stages ?What are the stages ?How do we treat ?How do we treat ?How does CIN differ from invasive How does CIN differ from invasive cancercancer

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Further readingFurther reading

http://www.cancerscreening.nhs.uk/http://www.cancerscreening.nhs.uk/cervical/publications/cervicalpocket2cervical/publications/cervicalpocket2004.pdf004.pdf

http://www.gfmer.ch/Books/Cervicalhttp://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_ins_cancer_modules/Aided_visual_inspection_atlas.htmpection_atlas.htm

http://www.cancerscreening.nhs.uk/cervical/publications/cervicalpocket2004.pdf



http://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_inspection_atlas.htm



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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical ScreeningCervical ScreeningGeneralGeneral screeningscreening criteriacriteria

The disease should be responsible for The disease should be responsible for significant morbidity or mortality in the target significant morbidity or mortality in the target population population The natural history of the disease should be The natural history of the disease should be known known Intervention at an early stage should be Intervention at an early stage should be effective in preventing the condition effective in preventing the condition A screening programme should be cost effective A screening programme should be cost effective Treatment should cause low morbidity Treatment should cause low morbidity

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical ScreeningCervical Screening

Almost four million women are Almost four million women are screened each year screened each year

42% fall in incidence of cervical 42% fall in incidence of cervical cancer between 1988 and 1997 cancer between 1988 and 1997 attributable to screening attributable to screening

Mortality rates in 2000 were 60% Mortality rates in 2000 were 60% lower than 30 years earlier lower than 30 years earlier

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical ScreeningCervical ScreeningThe screening programme in England and The screening programme in England and Wales invites all women between 25 and 64 Wales invites all women between 25 and 64 years for threeyears for three-- or fiveor five--yearly screening. yearly screening.

It is recommended that women 25 to 49 are It is recommended that women 25 to 49 are screened threescreened three--yearly and 50 to 64 five yearly. yearly and 50 to 64 five yearly.

Women over 65 are only called if they have not Women over 65 are only called if they have not had a smear since age 50, or have had a recent had a smear since age 50, or have had a recent abnormality. abnormality.

In Scotland the programme is slightly different, with women In Scotland the programme is slightly different, with women between the ages of 20 and 60 being invited for screening every between the ages of 20 and 60 being invited for screening every three years. three years.

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical Intraepithelial Cervical Intraepithelial NeoplasiaNeoplasia

CIN ICIN I-- Dysplasia in the basal 1/3 Dysplasia in the basal 1/3

CIN 2CIN 2-- Dysplasia extending to middles Dysplasia extending to middles 1/31/3

CIN 3CIN 3-- Dysplasia involving the whole Dysplasia involving the whole epithelium but the basal membrane is epithelium but the basal membrane is intact.intact.

DysplasiaDysplasiabasal hyperplasia basal hyperplasia -- multimulti--layering of basal cells layering of basal cells nuclear nuclear pleiomorphismpleiomorphismincreased mitotic activityincreased mitotic activity

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical CancerCervical Cancer

IncidenceIncidence

2400 new cases per year in England and 2400 new cases per year in England and WalesWales

<1000 deaths annually<1000 deaths annually

½½ of women who present with late stage of women who present with late stage disease have never had a smeardisease have never had a smear

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening


AgeAge

Rare under 20yrsRare under 20yrsPeak 45Peak 45--55yrs55yrsPeaks earlier in pts from lower Peaks earlier in pts from lower socioeconomic groupssocioeconomic groups

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical CancerCervical CancerRisk factorsRisk factors

AgeAgeLower social classLower social classHPV infection (types 16 and 18 mainly)HPV infection (types 16 and 18 mainly)Large numbers of sexual partnersLarge numbers of sexual partnersPartner with many previous partnersPartner with many previous partnersSmokingSmokingImmunosuppressionImmunosuppressionEarly age of 1Early age of 1stst intercourse and 1intercourse and 1stst pregnancypregnancyAbnormal smearAbnormal smearOral contraceptive use rather than barrierOral contraceptive use rather than barrier

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening


Pathology Pathology -- micromicro

80% squamous carcinoma of 80% squamous carcinoma of transformation zonetransformation zone

Rest are adenocarcinomaRest are adenocarcinoma

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Cervical smear

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devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening


Pathology Pathology –– macromacro

Ulceration or mass on cervix that Ulceration or mass on cervix that bleeds easilybleeds easily

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Cervical smear

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Further reading

Cervical Cancer

incidence

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risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening


Common PresentationsCommon Presentations

During routine smearDuring routine smearPostcoital bleedingPostcoital bleedingIntermenstrual bleedingIntermenstrual bleedingPostmenopausal bleedingPostmenopausal bleedingOffensive vaginal dischargeOffensive vaginal dischargePainPain

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Cervical smear

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Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

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pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

Cervical CancerCervical CancerInvestigationsInvestigations

Urgent referral for colposcopyUrgent referral for colposcopyDirect visualisationDirect visualisationGreen light Green light –– abnormal blood vesselsabnormal blood vesselsAcetic acid Acetic acid –– causes coagulation of nuclear causes coagulation of nuclear proteins, hence areas of high nuclear density proteins, hence areas of high nuclear density appear whiteappear whiteIodine Iodine –– SchillerSchiller’’s test s test –– abnormal immature abnormal immature epithelium doesnepithelium doesn’’t contain glycogen and t contain glycogen and therefore doesntherefore doesn’’t stain with iodinet stain with iodine

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Cervical smear

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Further reading

Cervical Cancer

incidence

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pathology – micro

pathology – macro

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investigation

Cervical Screening

Other testOther test

FBCFBCU&EU&ELFTLFTSerum CaSerum CaChest XChest X--rayrayCT scanCT scanIn advanced disease consider In advanced disease consider cystoscopy / sigmoidoscopy cystoscopy / sigmoidoscopy

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Cervical smear

methods

devices

Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology – micro

pathology – macro

presentation

investigation

Cervical Screening

TreatmentTreatment

Depend on the stage of the diseaseDepend on the stage of the disease

Cone biopsyCone biopsy

Radiotherapy Stage IRadiotherapy Stage I--IVIVChemotherapy for some casesChemotherapy for some cases

Radical Hysterectomy

cervical speculum examination. - the hillingdon · pdf filecervical speculum examination and...

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