APGOClinicalSkillsCurriculum

CervicalCytology,
WetPrepandCervical
CultureCollection

AssociationofProfessorsofGynecologyandObstetrics(APGO)
UndergraduateMedicalEducationCommittee2008

CervicalCytology,WetPrep
andCervicalCultureCollection

TableofContents

IntendedLearningOutcomes

DescriptionoftheCervicalCytology,WetPrepandCervical/
VaginalCultureCollectionProcedure

BestPractices

Checklist

PerformanceAssessment

PracticalTips

Resources

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IntendedLearningOutcomes

DifferingonlyslightlyfromtheAmericanCancerSociety(ACS)andtheU.S.Preventive
ServicesTaskForce(USPSTF)recommendations,theAmericanCollegeofObstetricians
andGynecologists(ACOG),initsCervicalCytologyScreeningTechnicalBulletin,
publishedin2003,recommendstheinitiationofscreeningcervicalcytologyby21years
ofageorwithinthree(3)yearsofcoitarche,andcontinuingannuallytoage30years.12
Afterthree(3)consecutivenormalcytologies,cervicalcytologycanbedoneeverytwoto
three(23)yearssolongasitremainsnormal.IfHPVtesting,riskprofileandcytologyis
negative,thencombinedscreeningshouldberepeatednomorethaneverythreeyears.

Ifthereisnohistoryofcervicalabnormalities,thepatientandclinicianmaydecideto
discontinuescreeningcytologyatage6570yearsorfollowingahysterectomy(for
benignindications).

Thecollectionofcervical/vaginalmaterialforculturesandwetprepisgenerallydone
foraspecificindication,suchasvaginitisorforscreeningforsexuallytransmitted
infections.Variousvaginalconditions,includingvulvovaginalcandidiasis,bacterial
vaginosis,trichomoniasisandleukocytosis,canbevisualizedonwetprep.

Thecervicalcytologyscreeningvisitisalsoanopportunitytoaddressandcounsel
patientsonvariousadditionalissues.

Thelearningobjectivesofcervicalcytologycollectionareto:

1. Demonstrateunderstandingofthebackground,techniqueandinterpretationof
traditionalslideandliquidbasedcervicalcytology

2. Demonstratetheappropriatetechniqueincollectingcervicalcytology

3. Describethescreeningintervalsindifferentagegroups

4. Counselpatientsappropriatelyabouttheroleofcervicalcytologyinthe
detectionofcervicalcanceranddysplasia

5. Communicatewiththepatientinarespectful,sensitivemannerduringthe
examination

DescriptionoftheCervicalCytologyandCervical/VaginalCulture
CollectionProcedure

GeneralApproach/CommunicationSkills

Thestudentshould:
1. Introducehimorherselftothepatient,confirmthepatientsnameandhowshe
wishestobeaddressed.
2. Washhands(oruseanalcoholbasedantiseptic)anddonnonlatexgloves.If
thesearenotavailable,aninquiryaboutlatexallergyisnecessarybefore
proceeding.
3. Explainthepurposeoftheexaminationandgeneralstepsbeforebeginning.If
thisisthepatientsfirstexamination,thestudentshouldexplainthoroughly,and
showthespeculumandcervicalcytologycollectiondevicestothepatient.
4. Drapepatientappropriately.
5. Besensitivetopatientdiscomfortthroughouttheexaminationandprovide
opportunitiesforthepatienttoaskquestions.

CervicalCytologyCollection

Thestudentshould:
1. Selecttheappropriatesizedspeculum,warmspeculumandtestspeculumon
patientslegforcomfortabletemperature.
2. Informpatientpriortospeculuminsertion.
3. Insertspeculumat45degreedownwardangle,thenrotateandopenwhen
completelyinserted.
4. Visualizethecervixbyadjustingthespeculumanteriorlyorposteriorly.

TraditionalSlideCytologyCollection

Thestudentshould:
5. Usethespatulacloverleafendtocollectectocervicalcells,orspatulaendfor
vaginalcuffcells,andthensmeartheminathinlayerontheslide.
6. Onthesameslide,smearendocervicalcellscollectedusingacytobrush.Only
insertcytobrushsuperficiallyinpregnancy.
7. Thestudentorassistantshouldspraytheslidewithcytologyfixative
immediatelyaftercytologycollectionandplaceitintheappropriatecontainer.
8. Thestudentorassistantshouldlabelthecontainerappropriately.

LiquidBasedCytologyCollection:

9. Studentshouldfirstusetheplastic(notwood)spatulatocollectectocervicalcells
(rotate360degrees),thenbrushlikedevice(rotate180degrees)tocollect
endocervicalcells.Onlyinsertbrushsuperficiallyinpregnancy.
10. Bothspatulaandbrushshouldbesweptaroundtheinsideoftheliquidbased
cytologyspecimencollectioncontainer10timestoloosenthemaximumnumber
ofcervicalcellsintosolution.
11. Thestudentorassistantshouldlabelthecontainerappropriately.

TraditionalCytologySmearCollection

TraditionalSlidePreparation

LiquidBasedCytology

LiquidCytologyPreparation

NormalCervix

Cervical/VaginalCultureCollection

Thestudentshould:

1. Selectappropriatesizedspeculum,warmspeculumandtestspeculumonthe
patientslegforcomfortabletemperature

2. Informpatientpriortospeculuminsertion

3. Insertspeculumat45degreeanglethenrotateandopenwhencompletely
inserted

4. Visualizethecervixbyadjustingthespeculumanteriorlyorposteriorly

5. Usetheappropriatecollectionvialwiththecorrectattachedswabforeach
culture

6. ForChlamydiaandGonorrheacervicalcultures,inserttheswabintothe
endocervixforapproximately10seconds(insertonlysuperficiallyinpregnancy)

7. Forvaginalcultures,obtainaspecimenfromtheposteriorfornix

8. Inserttheswabintothevial,breakofftheexcessswabandcapoffthecollection
vial/tubesecurelyandlabelthespecimen

WetPrepInterpretation

Thestudentshould:

1. Proceedasforvaginalculturecollectionandobtainasampleofvaginalfluid

2. Onasingleglassslide,placeadropofNaCl.andadropofKOH

3. Mixasmallamountofvaginalfluidwitheachsolutionandapplycoverslip

4. Immediatelyafterpreparation,takethepreparedslidetothemicroscopeanduse
lowmagnification(10x)tofocus

5. Lookforcluecells,whitecellsandtrichomonadsontheNaClfield,andfor
buddinghyphaeontheKOHfield

6. Performawhifftestand,ifavailable,checkforpH

7. Discussfindingsandtreatmentwithsupervisingclinicianandpatient

BestPractices

Wefoundthatmoststudentsareintroducedtothesebasicskillsduringclinicalskills
courses.Insomeinstances,opportunitiestoperformtheseskillsongynecologicexam
instructorsorstandardizedpatientswouldfollow.Thereiscurrentlyadearthof
simulationtypeorWebbasedopportunitiestopracticetheseskillsoutsidetheclinical
arena.Moststudentsgainthemajorityofopportunitiestoperformtheskillsduringtheir
clinicalclerkshipintheformofsupervisedclinicalcontact.

Aninformalsurveyof17medicalschoolsaroundthecountryconfirmedthesefindings.
Weprovidethefollowingmaterialstohelpstandardizetheinstructionandevaluation
processinamannerconsistentwiththebestpracticesofacademicinstitutionsacrossthe
country.

Thereforewesuggestintroducinginstructionofcytology,cervicalculturecollectionand
wetprepasasimulationusingapelvicmodelandpreparedslidesofwetprepfindings,
andthensupplementingclinicalexperienceduringtheObstetricsandGynecology
clerkshipwithstandardizedpatientexperience.

Checklist

GeneralApproachand
CommunicationSkills
Properlyintroducedhimorherself
tothepatient
Establishedandmaintainedrapport
withthepatient
Washedhandsorusedanantiseptic
wash
Usedappropriatedraping
techniques
Performedtheexaminanorganized
fashion
Madethepatientfeelcomfortable
Usedgoodnonverbalskills
Closedtheexaminanappropriate
manner
CervicalCytologyCollection
Selectedappropriatesizedspeculum
andwarmedit
Insertedthespeculumcorrectlyand
visualizedthecervix
Collectedthecervicalcellscorrectly
usingspatulaandcytobrushtothe
pelviccurve
Usedcorrecttechniquetocollect
cellsintothevial
Labeledthespecimenappropriately
Cervical/VaginalCultureandWet
PrepCollection
Selectedappropriatesizedspeculum
andwarmedit
Insertedthespeculumcorrectlyand
visualizedthecervix
Usedtheappropriatecollectionvial
forthespecimen
Foracervicalculture,placedthe
swabintheendocervixfor10
seconds

Well
Done

Needs
Improvement

Not
Done

Cannot
Recall

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Foravaginalculture,obtained

specimenfromtheposteriorvaginal
fornix
Cappedoffandlabeledspecimen

appropriately
Preparedslideforwetprepcorrectly

Correctlyidentifiedyeast,cluecells,

trichomonas,squamouscellsand
whitebloodcells,ifpresent
Appropriatelydiscussedfindings

andtreatmentwithsupervising
clinician

GlobalAssessment

Studentsoverallperformancewas:
ExcellentVeryGoodGoodFairPoor

PerformanceAssessment

Thecervicalcytologyandcervical/vaginalculturecollectionskillsarebestassessed
throughdirectobservationofeitheraclinicalencounter,astandardizedpatient
encounterorsimulatedsessionusingapelvicmodel.Thewetprepcollectionand
interpretationskillsarebestassessedusingvaginalfluid,ifavailable,orothersimilar
material(suchashandlotion).Ifthelatterisused,thestudentshouldhaveaccessto
preparedslidesdemonstratingthefindingscommonlyseenonawetprep,suchasclue
cells,whitecells,trichomonadsorhyphae.

Theprecedingchecklistcanbeusedforperformanceassessmentofaclinicalencounter.
Belowisacasescenario,whichcanbeusedforstandardizedpatientstation,followedby
anexampleofapostencounternote,ifdesired(modeledafterUSMLEClinicalSkills
Exam).

InstructionsfortheCervicalCytology,Cultures,WetPrepStation

Thisstationis30minutesinlength.Thefirst15minutesarespentinterviewingthe
patientandperformingappropriatephysicalexam.Thelast15minutesarespent
writingapostencounternote,whichincludespertinenthistory,physicalexamfindings,
differentialdiagnosis,anddiagnosticworkupplan.

Pleasenotethatstudentsareexpectedtoobtainafocusedhistory,familyhistory,social
historyandmedications,andtocollectacervicalcytology,cervicalandvaginalcultures,

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andadditionalvaginalfluidforthepreparationofawetprep.Makesuretheydiscuss
withthepatienttheirinitialdiagnosticimpressionandworkupplan.

Oncestudentsleavetheexaminationroom,theymaynotreenter.Theyareexpectedto
completetheirnoteandgiveittothestaffwhenfinished.

CaseScenario

Thisisa15minutestation;thestaffmemberwillknockonthedoorwhenfive(5)
minutesremainandattheendofthesession.

MissJonesisa22yearoldwomancomingtotheclinicbecauseofvaginalitchingand
burning.Shehasneverhadapelvicexam.
Vitalsigns:BP120/80 P70/min
R14/min
Temp98.6degreesF

Thestudentstasksareto:
1. Obtainafocusedhistory

2. Performarelevantphysicalexaminationandspecimencollection,includingwet
prep

3. Discussinitialdiagnosticimpressionandworkupplanwiththepatient

4. Afterleavingtheroom,completepatientnoteontheformprovided

PostEncounterNote

History:Includesignificantpositivesandnegativesfromhistoryofthepresentillness,
pastmedicalhistory,reviewofsystems,socialhistory,andfamilyhistory.

HPI:Gravida/Para,duration,severityandnatureofsymptoms,LMP,whetherpregnant,
whethersexuallyactive,lengthoftimewithcurrentpartner,previouspartners,LMP
normal?
PMHx:h/oSTIs,abnormalpapsmears,HPV;ageatmenarche,coitarche
PSHX:cervicalsurgery
Social:Smoking,alcoholuse,#ofsexualpartnersinlifetime
FamilyHx:Breast,cervicalorovariancancer
Medications:hormonalcontraception,HRT

PhysicalExamination:Indicateonlypertinentpositiveornegativefindingsrelatedtothe
patientschiefcomplaint.

Cervicalandvaginalappearance

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?bleedingwithcytologycollection
Vaginaldischargecolor,consistency,odor,amount
Wetprepfindings

DifferentialDiagnoses:Inorderof
likelihood(with1beingthemostlikely),
listupto5potentialorpossible
diagnosesforthispatientspresentation
(inmanycases,fewerthan5diagnoses
arelikely):

1.Vulvovaginalcandidiasis

DiagnosticWorkup:Listimmediate
plans(upto5)forfurtherdiagnostic
workup:

1.Wetprep

2.Bacterialvaginosis

2.CervicalcytologywithreflexHPV

3.Physiologicdischarge

testing

4.

3.HPVvaccine

5.

4.CervicalculturesforGC/chlamydia

5.

PracticalTips

Wesuggestthatthecervicalcytology,culturesandwetprepskillsexaminationbe
introducedtostudentsduringthefirsttwoyearsofmedicalschoolintheformof
didactics,practiceonmodelsandastandardizedpatientexercise(SP).TheSPshouldbe
repeatedduringtheclinicalyears,iffeasible,tosupplementthestudentsclinical
experience.Theperformanceassessmentshouldoccuraspartofanobjectivestructured
clinicalexaminationatendoftheObstetricsandGynecologyclerkshiporattheendof
thethirdyear.

Resources

1.AmericanSocietyforColposcopyandCervicalPathology;www.asccp.org.

2.AmericanCollegeofObstetriciansandGynecologistsTechnicalBulletin:Cervical
cytologyscreening,2003.

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