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Specimen Collection Papanicolaou (Pap) Smear: Overview, Indication, Procedure

Specimen Collection Papanicolaou (Pap) Smear: The Pap smear is a tool for screening of cervical cancer. Appropriate smear collection is paramount to the detection of cancer cells. In addition, if a lesion is seen or palpated, other tests, such as an ultrasound examination of the pelvis or colposcopy, should be performed in conjunction with the Pap smear.

OVERVIEW OF PAPANICOLAOU (pap) SMEAR

• Adequacy of the specimen is shown by the presence of 

    • Endocervical cells 

    •Squamous metaplasia (found in the transformation zone )

          • The transformation zone is found inside the cervical os; this is an area of replacement of endocervical columnar cells by squamous cells and varies with age. In perimenopausal women, the transformation zone is found high in the endocervical canal.

• The practitioner should be familiar with the classification of cervical smears.

RATIONALE OF PAPANICOLAOU (pap) SMEAR

  • To detect cervical carcinoma 

 • To detect early cervical dysplasia related to infection with HPV

Cervical Smear Classifications

CLASSDESCRIPTIVEBETHESDACIN
Class INegativeWNLNegative
Class IIInflammatory, squamous,
koilocytotic atypia
Reactive, reparative changes,
ASCUs, LSIL (HPV)
Class IIIMild dysplasia
Moderate dysplasia
Severe dysplasia
LSIL (HPV)
HSIL
HSIL
CIN1
CIN2
CIN3
Class IVCa in situHSILCIN3
Class VInvasiveInvasiveInvasive
ASCU = Atypical squamous cell undetermined; CIN = cervical intraepithelial neoplasia; HPV =
Human papillomavirus; HSIL = high-grade intraepithelial lesion; LSIL = low-grade intraepithelial lesion;
WNL = within normal limits

INDICATIONS OF PAPANICOLAOU (pap) SMEAR

 • Abnormal vaginal bleeding or discharge 

 • Lower abdominal pain 

 • Yearly screening 

 • Visible or palpable cervical lesions 

 • Report of cervical dysplasia or malignancy on previous Pap smear 

 • DES-exposed female—REFER to gynaecologist for treatment. 

 • History of sexually transmitted disease 

 • History of multiple sexual partners 

CONTRAINDICATIONS OF PAPANICOLAOU (pap) SMEAR

 • Pelvic inflammatory disease 

 • Active vaginitis 

 • Active cervicitis 

PROCEDURE OF PAPANICOLAOU (pap) SMEAR

Equipment 

 • Vaginal speculum—small, medium, or large 

 • Drape—nonsterile 

 • Gloves—nonsterile 

 • Light source 

 • Pap smear kit or liquid-based kit (usually provided by the reference laboratory

      • Wooden paddle and cotton-tipped applicator 

     • Optional—cytobrush (decreases the chance of a false-negative result) 

     • Cervical broom  

     • Microscope slides 

     • Fixative

• Water-soluble lubricant—K-Y jelly 

 • Large cotton-tipped swabs 

Procedure 

 • Place the client in the lithotomy position and drape. 

 • Put on gloves. 

 • Examine the vulva and Bartholin’s and Skene’s glands. 

 • Warm the speculum with water or lubricate with water-soluble lubricant. 

 • Ask the client to relax and breathe deeply (this may help the client to relax). 

 • Insert the speculum at a slight diagonal angle and rotate to a horizontal angle as inserting. Direct the speculum in a downward posterior direction, applying gentle pressure.

• Open the speculum and adjust the position until the cervix is easily visible. 

 • Observe the cervix and vaginal wall for inflammation and/or infection, cysts, lesions, or bleeding. 

 • If necessary, absorb discharge or blood with large cotton-tipped swab.

• Pap smear kit : 

    • Insert the wooden paddle into the cervix and rotate 360 degrees. 

    • Place the smear on the slide indicated in the Pap smear kit. 

    • Insert other end of the wooden paddle and brush the ectocervix and vaginal wall. 

    • Apply this specimen to the slide indicated in the Pap smear kit. 

    • Next, insert the cytobrush, broom, or cotton-tipped applicator in the cervical os and rotate 360 degrees. 

    • Apply this specimen to the slide indicated in the Pap smear kit. 

    • Apply fixative provided to the slides. 

    • Label and send to reference laboratory. 

• Liquid-based kit : 

    • Insert the cytobrush in the cervix and rotate 360 degrees. 

    • Insert the paddle into the cervix and rotate 360 degrees. 

    • Put both specimens in the specimen bottle. 

    • Snap off the handles and apply the lid. 

    • Label and send to reference laboratory.

• Hint —With postmenopausal and obese clients, the vaginal walls may prolapse into the open speculum, occluding your view of the cervix. To prevent this complication, a special splint using a glove and the speculum can be used. You can make this splint by 

    • Inserting the speculum into the finger of a nonsterile glove 

    • Removing the excess glove 

    • Cutting off the  fingertip 

• The glove provides a splintlike effect when the speculum is opened in the vagina.

Specimen Collection Papanicolaou (Pap) Smear

 Client Instructions 

• There may be minor bleeding after the examination. This is normal. 

• If your Pap smear is class II through V, further testing is necessary. 

• The nurse from the office will call you in 5 to 10 days with the results of your Pap smear.

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