cervical speculum examination

7/26/2019 Cervical Speculum Examination

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Speculum examination

Inspection of vagina

Inspection of cervix

Cervical smear

methods

devices

Slide method

Liquid-based cytology

SwabsRemoving the speculum

Ending the procedure

Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening

Cervical speculum examinationCervical speculum examination

and taking a smear.and taking a smear.

Cusco

Sims


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Cervical smear

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Slide method




Summary

Further reading

Cervical Cancer

incidence

age

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pathology micro

pathology macro

presentation

investigation

Cervical Screening

Learning OutcomesLearning Outcomes

Able assemble the speculumAble assemble the speculumcorrectlycorrectly

Able to inspect vagina and cervixAble to inspect vagina and cervixusing a speculumusing a speculum

Perform a cervical smearPerform a cervical smear


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Cervical smear

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Slide method




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 theDesigned for the inspection of the

cervix and vaginal walls.cervix and vaginal walls.Bivalve (cusco) speculum is the instrumentBivalve (cusco) speculum is the instrument

most commonly used to inspect themost commonly used to inspect thevaginavagina

2. Access to the cervix and fornices2. Access to the cervix and fornices

for bacteriological swabs andfor bacteriological swabs andcervical smears.cervical smears.


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Cervical smear

methods

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Slide method




Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening

ExaminationExamination

GRIPGRIP

Greet, rapport, introduce and identify, explainGreet, rapport, introduce and identify, explainprocedureprocedure

Tell the patient the procedure is notTell 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 menstruating

no spermicide, lubricant, sexual intercourseno spermicide, lubricant, sexual intercourse

in the previous 48 hours.in the previous 48 hours.


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Cervical smear

methods

devices

Slide method




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 toyour bottom and let your knees flop apart


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Cervical smear

methods

devices

Slide method




Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening


Warm blades under a stream of tepidWarm blades under a stream of tepid

water.water. Wear gloves, prepare the slide/bottleWear gloves, prepare the slide/bottle

Write name of the patient, date and timeWrite name of the patient, date and time

of taking the specimen withof taking the specimen with pencilpencil notnotpen if usingpen if using slideslide

Hold the speculum with dominant hand,Hold the speculum with dominant hand,

separate the labia and expose introitusseparate the labia and expose introituswith nonwith non--dominant handdominant hand

Tell the patient you are about toTell the patient you are about to

introduce the speculum and reassureintroduce the speculum and reassure


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Cervical smear

methods

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Slide method




Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening


Slide the closed blades obliquely overSlide the closed blades obliquely over

the fingers into the introitus , introducethe fingers into the introitus , introducethe instrument into the vaginathe instrument into the vagina

While inserting the instrument rotate it toWhile inserting the instrument rotate it toa clockwise direction until the anteriora clockwise direction until the anteriorand posterior blades run along theand posterior blades run along the

anterior and posterior vaginal walls withanterior and posterior vaginal walls withthe handles pointing towards the anus orthe handles pointing towards the anus orclitoris.clitoris.


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Cervical smear

methods

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Slide method




Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening


Maintain a downward pressure, onMaintain a downward pressure, on

the speculum and press on thethe speculum and press on thethumb piece to hinge the bladesthumb piece to hinge the blades

open to expose the vaginal vaultopen to expose the vaginal vault

and cervix.and cervix.

Adjust the light source to illuminateAdjust 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

Removing the speculum


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:

NormalNormalclear / 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 ofwith pain, itching, swelling and erythema ofthe vulva)the vulva)

Frothy, fishy odour:Frothy, fishy odour: TrichomoniasisTrichomoniasis

Asymptomatic discharge: gonorrhoeaAsymptomatic discharge: gonorrhoea

UlcersUlcers

Foreign 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 posteriorlyCervix normally points posteriorly

and inferiorlyand inferiorly

Look for:Look for:

DischargeDischarge

CystsCysts

PolypsPolyps

Ulceration or fungating growthUlceration or fungating growth


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Cervical smear

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Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening

NormalNormal with

ectropion

cervicitis cancer


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Cervical smear

methods

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Slide method


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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

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Slide method


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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 afterCervical 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 tosquamous)


15/41

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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 -- methodsmethods

Newer method =Newer method = LBCLBC (( LiquidLiquidbasedbased

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 fixative

Fewer inadequate samples. Being rolled outFewer inadequate samples. Being rolled outacross the UKacross the UK

Older method =Older method = slidesslides Use 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 smearCervical smear -- devicesdevices

LBCLBC

A cervex brush isA cervex brush iscommonly usedcommonly used

SlideSlide--basedbased

A wooden spatulaA wooden spatula

is used with a bifidis used with a bifidend (Aylesburyend (Aylesbury

spatula) .spatula) .


17/41

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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 os

Twirl 10 timesTwirl 10 times Place brush in fixative bottle and dipPlace brush in fixative bottle and dip

/ stir / squish vigorously to wash the/ stir / squish vigorously to wash thecells off the brush into the bottlecells off the brush into the bottle


18/41

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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 theThe bifid end is used to harvest the

cervical cells.cervical cells. Introduce the spatula through theIntroduce the spatula through the

speculum and position the bifid endspeculum and position the bifid endat the os.at the os.

Rotate through 360Rotate through 360


19/41

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Cervical smear

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Slide method


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Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening

The desquamating cells areThe desquamating cells arecollected by rotating the spatulacollected by rotating the spatula

around the circumference of thearound the circumference of the

os and the lips of the cervix.os and the lips of the cervix.


20/41

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Cervical smear

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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 theSpread the cervical material onto the

labelled glass slide by stroking eachlabelled glass slide by stroking each

side of the bifid end of the spatulaside of the bifid end of the spatula

along the glassalong the glass


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Cervical smear

methods

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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 mucusThe cervical cells and some mucus

should cling to the glass.should cling to the glass. Immediately spray the slides withImmediately spray the slides with

fixative or fix them by immersion infixative or fix them by immersion in95% alcohol95% alcohol

Do not allow the sample to dry.Do not allow the sample to dry.

Some examples of cells processed with the Papanicolau stain


22/41

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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 ofIf any ulcers, take swab from base of

ulcer.ulcer.

If infection suspected, take swab fromIf infection suspected, take swab from

cervix or high vaginal.cervix or high vaginal.


23/41

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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 screw

Simultaneously withdraw the speculumSimultaneously withdraw the speculumand rotate the open blades to ensure thatand rotate the open blades to ensure that

the anterior and posterior walls of vaginathe anterior and posterior walls of vagina

can be inspected.can be inspected. Near the introitus, allow the blades toNear the introitus, allow the blades to

closeclose

Taking care not to pinch the labia or anyTaking care not to pinch the labia or any

hairs while withdrawing the speculum.hairs while withdrawing the speculum.


24/41

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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 haveTell the patient that you have

finished , give a towel to the patientfinished , give a towel to the patientto 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

Further ReadingFurther Reading

Why screen regularly with smearWhy screen regularly with smear

testtest What 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 invasiveHow does CIN differ from invasivecancercancer


27/41

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Cervical smear

methods

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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_ins

pection_atlas.htmpection_atlas.htm
http://www.cancerscreening.nhs.uk/cervical/publications/cervicalpocket2004.pdfhttp://www.cancerscreening.nhs.uk/cervical/publications/cervicalpocket2004.pdfhttp://www.cancerscreening.nhs.uk/cervical/publications/cervicalpocket2004.pdfhttp://www.cancerscreening.nhs.uk/cervical/publications/cervicalpocket2004.pdfhttp://www.cancerscreening.nhs.uk/cervical/publications/cervicalpocket2004.pdfhttp://www.cancerscreening.nhs.uk/cervical/publications/cervicalpocket2004.pdfhttp://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_inspection_atlas.htmhttp://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_inspection_atlas.htmhttp://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_inspection_atlas.htmhttp://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_inspection_atlas.htmhttp://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_inspection_atlas.htmhttp://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_inspection_atlas.htmhttp://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_inspection_atlas.htmhttp://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_inspection_atlas.htmhttp://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_inspection_atlas.htmhttp://www.cancerscreening.nhs.uk/cervical/publications/cervicalpocket2004.pdfhttp://www.cancerscreening.nhs.uk/cervical/publications/cervicalpocket2004.pdfhttp://www.cancerscreening.nhs.uk/cervical/publications/cervicalpocket2004.pdf


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Cervical smear

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Slide method


Swabs



Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening

Cervical ScreeningCervical Screening

GeneralGeneral screeningscreening criteriacriteria

The disease should be responsible forThe disease should be responsible forsignificant morbidity or mortality in the targetsignificant morbidity or mortality in the targetpopulationpopulation

The natural history of the disease should beThe natural history of the disease should beknownknown

Intervention at an early stage should beIntervention at an early stage should be

effective in preventing the conditioneffective in preventing the condition A screening programme should be cost effectiveA screening programme should be cost effective

Treatment should cause low morbidityTreatment should cause low morbidity


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Cervical smear

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Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening


Almost four million women areAlmost four million women are

screened each yearscreened each year

42% fall in incidence of cervical42% fall in incidence of cervicalcancer between 1988 and 1997cancer between 1988 and 1997attributable to screeningattributable to screening

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


31/41

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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 screening programme in England andThe screening programme in England andWales invites all women between 25 and 64Wales 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 areIt is recommended that women 25 to 49 arescreened 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 notWomen over 65 are only called if they have nothad a smear since age 50, or have had a recenthad a smear since age 50, or have had a recent

abnormality.abnormality.

In Scotland the programme is slightly different, with womenIn Scotland the programme is slightly different, with womenbetween the ages of 20 and 60 being invited for screening everybetween the ages of 20 and 60 being invited for screening everythree years.three years.


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Cervical smear

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Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening

Cervical IntraepithelialCervical Intraepithelial

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

CIN 2CIN 2-- Dysplasia extending to middlesDysplasia extending to middles1/31/3

CIN 3CIN 3-- Dysplasia involving the wholeDysplasia involving the whole

epithelium but the basal membrane isepithelium but the basal membrane isintact.intact.

DysplasiaDysplasia

basal hyperplasiabasal hyperplasia -- multimulti--layering of basal cellslayering of basal cells nuclearnuclear pleiomorphismpleiomorphism

increased mitotic activityincreased mitotic activity


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Cervical smear

methods

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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 and2400 new cases per year in England and

WalesWales


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Cervical smear

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Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening


AgeAge

Rare under 20yrsRare under 20yrs

Peak 45Peak 45--55yrs55yrs Peaks earlier in pts from lowerPeaks earlier in pts from lower

socioeconomic groupssocioeconomic groups


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Cervical smear

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Summary

Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening


Risk factorsRisk factors

AgeAge

Lower social classLower social class

HPV infection (types 16 and 18 mainly)HPV infection (types 16 and 18 mainly)

Large numbers of sexual partnersLarge numbers of sexual partners

Partner with many previous partnersPartner with many previous partners

SmokingSmoking

ImmunosuppressionImmunosuppression

Early age of 1Early age of 1stst intercourse and 1intercourse and 1stst pregnancypregnancy

Abnormal smearAbnormal smear

Oral contraceptive use rather than barrierOral contraceptive use rather than barrier


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Further reading

Cervical Cancer

incidence

age

risk factors

pathology micro

pathology macro

presentation

investigation

Cervical Screening


PathologyPathology -- micromicro

80% squamous carcinoma of80% squamous carcinoma of

transformation zonetransformation zone

Rest are adenocarcinomaRest are adenocarcinoma


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Cervical Screening


PathologyPathology macromacro

Ulceration or mass on cervix thatUlceration or mass on cervix that

bleeds easilybleeds easily


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Further reading

Cervical Cancer

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pathology macro

presentation

investigation

Cervical Screening


Common PresentationsCommon Presentations

During routine smearDuring routine smear

Postcoital bleedingPostcoital bleeding Intermenstrual bleedingIntermenstrual bleeding

Postmenopausal bleedingPostmenopausal bleeding

Offensive vaginal dischargeOffensive vaginal discharge

PainPain


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Cervical Cancer

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pathology macro

presentation

investigation

Cervical Screening


InvestigationsInvestigations

Urgent referral for colposcopyUrgent referral for colposcopy Direct visualisationDirect visualisation

Green lightGreen lightabnormal blood vesselsabnormal blood vessels

Acetic acidAcetic acidcauses coagulation of nuclearcauses coagulation of nuclearproteins, hence areas of high nuclear densityproteins, hence areas of high nuclear densityappear whiteappear white

IodineIodineSchillerSchillers tests testabnormal immatureabnormal immatureepithelium doesnepithelium doesnt contain glycogen andt contain glycogen andtherefore doesntherefore doesnt stain with iodinet stain with iodine


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Summary

Further reading

Cervical Cancer

incidence

age

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pathology micro

pathology macro

presentation

investigation

Cervical Screening

Other testOther test

FBCFBC

U&EU&E

LFTLFT

Serum CaSerum Ca Chest XChest X--rayray

CT scanCT scan

In advanced disease considerIn advanced disease considercystoscopy / sigmoidoscopycystoscopy / 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--IVIV

Chemotherapy for some casesChemotherapy for some cases

Radical

Hysterectomy

cervical speculum examination

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