Cervical Speculum Examination PDF

Cervical speculum examination
Jump menu
and taking a smear.
Title page
Speculum examination
Inspection of vagina
Inspection of cervix
Cervical smear
methods
devices
Slide method
Liquid-based cytology
Swabs Cusco
Removing the speculum
Ending the procedure
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
Sims
Learning Outcomes
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Title page
Able assemble the speculum

Cervical smear
methods
devices
Slide method
correctly
Able to inspect vagina and cervix
Swabs
using a speculum
Summary
Further reading
Perform a cervical smear

Cervical Cancer
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
1. Designed for the inspection of the
Jump menu
Title page
cervix and vaginal walls.
Cervical smear
methods Bivalve (cusco) speculum is the instrument
devices
Slide method most commonly used to inspect the
Swabs
vagina
Summary
Further reading
Cervical Cancer
incidence
2. Access to the cervix and fornices
age
risk factors
for bacteriological swabs and
pathology – micro
pathology – macro
presentation
cervical smears.
investigation
Cervical Screening
Examination
GRIP
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Title page
Greet, rapport, introduce and identify, explain
Cervical smear
methods
procedure
Tell the patient the procedure is not
devices
Slide method
Swabs
painful, but may be a bit uncomfortable.
Make sure:
Summary
Further reading
not menstruating
Cervical Cancer
incidence
age
risk factors
pathology – micro
no spermicide, lubricant, sexual intercourse
pathology – macro
presentation
in the previous 48 hours.
investigation
Cervical Screening
Position
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
“Lie on the couch, put your heels together, draw them up to
your bottom and let your knees flop apart”
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Title page
Warm blades under a stream of tepid
water.
Cervical smear
methods
Wear gloves, prepare the slide/bottle

devices
Slide method
Write name of the patient, date and time
Swabs
of taking the specimen with pencil not
Summary
pen if using slide
Further reading
Cervical Cancer
incidence
Hold the speculum with dominant hand,
age
risk factors
separate the labia and expose introitus
pathology – micro
pathology – macro
with non-dominant hand
presentation
investigation
Tell the patient you are about to
Cervical Screening
introduce the speculum and reassure
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Title page
Slide the closed blades obliquely over
the fingers into the introitus , introduce
Cervical smear
methods
the instrument into the vagina
devices
Slide method
While inserting the instrument rotate it to

Swabs
Summary
a clockwise direction until the anterior
Further reading
Cervical Cancer
and posterior blades run along the
incidence
age
anterior and posterior vaginal walls with
risk factors
pathology – micro
the handles pointing towards the anus or
pathology – macro
presentation clitoris.
investigation
Cervical Screening
Maintain a downward pressure, on
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Title page
the speculum and press on the

Cervical smear
methods
devices thumb piece to hinge the blades
Slide method
Swabs
open to expose the vaginal vault
and cervix.
Summary
Adjust the light source to illuminate

Further reading
Cervical Cancer
incidence
age
risk factors
pathology – micro
the vagina.
pathology – macro
presentation
investigation
Inspect vagina and cervix.
Cervical Screening
Inspection of the vagina
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Title page
Discharge:
Normal – clear / milky, odourless
Cervical smear
methods
Increased during ovulation, pregnancy, breast-
devices feeding, sexual arousal
Cottage cheese / curd-like: candida (assoc.
Slide method
Swabs
Removing the speculum with pain, itching, swelling and erythema of
Summary
the vulva)
Frothy, fishy odour: Trichomoniasis
Further reading
Cervical Cancer
Asymptomatic discharge: gonorrhoea

incidence
age
risk factors
pathology – micro
pathology – macro Ulcers
presentation
investigation
Cervical Screening
Foreign body
Inspection of the cervix
Cervix normally points posteriorly
Jump menu
Title page
and inferiorly
Cervical smear
methods
devices
Slide method
Swabs
Look for:
Discharge
Summary
Cysts
Further reading
Cervical Cancer
incidence
age
risk factors
pathology – micro
Polyps
pathology – macro
presentation
investigation
Ulceration or fungating growth
Cervical Screening
Normal with
Normal
ectropion
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
cervicitis cancer
Jump menu
Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
Nabothian cyst – mucus filled cervical cyst due to blockage of
a mucus gland
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Title page
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)

Cervical smear
Cervical smear performed after
Jump menu
Title page
inspecting the cervix.

Cervical smear
methods
devices The aim is to
Slide method
sample cells
Swabs from the
Removing the speculum transformation
Summary zone (where the
Further reading epithelium
Cervical Cancer
incidence changes from
age columnar to
risk factors
pathology – micro squamous)
pathology – macro
presentation
investigation
Cervical Screening
Cervical smear - methods
Newer method = LBC ( Liquid–based
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Title page
cytology )

Cervical smear
methods Use cervex brush (see next slide)
devices
Slide method
Dip brush into bottle of liquid fixative
Swabs
Removing the speculum Fewer inadequate samples. Being rolled out
Summary across the UK
Further reading
Cervical Cancer
incidence
age
risk factors Older method = slides
pathology – micro
pathology – macro
presentation
Use Aylesbury spatula (see next slide)
investigation
Cervical Screening
Spray or dip in fixative
Cervical smear - devices
Jump menu
Title page
LBC
Cervical smear
A cervex brush is
methods
devices
commonly used
Slide method
Swabs
Ending the procedure Slide-based
Summary
Further reading
Cervical Cancer
A wooden spatula
incidence
age is used with a bifid
risk factors
pathology – micro
pathology – macro
end (Aylesbury
presentation
investigation
spatula) .
Cervical Screening
Liquid Based Cytology method
Use a cervex brush
Jump menu
Title page
Cervical smear
Place the tip of the brush in the os

methods
devices
Slide method
Swabs
Twirl 10 times
Summary
Further reading
Cervical Cancer
Place brush in fixative bottle and dip
incidence
age / stir / squish vigorously to wash the
risk factors
pathology – micro
pathology – macro
cells off the brush into the bottle
presentation
investigation
Cervical Screening
Slide method
The bifid end is used to harvest the
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Title page
cervical cells.
Cervical smear
Introduce the spatula through the

methods
devices
Slide method
Swabs
speculum and position the bifid end
Summary
at the os.
Rotate through 360°
Further reading
Cervical Cancer
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
Jump menu
Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
The desquamating cells are
pathology – micro
pathology – macro
presentation
collected by rotating the spatula
investigation
Cervical Screening
around the circumference of the
os and the lips of the cervix.
Slide method
Send sample to the lab
Jump menu
Title page
Cervical smear
Spread the cervical material onto the

methods
devices
Slide method
Swabs
labelled glass slide by stroking each
Ending the procedure side of the bifid end of the spatula
Summary
Further reading
Cervical Cancer
along the glass
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
Slide method
The cervical cells and some mucus
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Title page
should cling to the glass.

Cervical smear
Immediately spray the slides with

methods
devices
Slide method
Swabs
fixative or fix them by immersion in
Summary
95% alcohol
Do not allow the sample to dry.
Further reading
Cervical Cancer
incidence
age
risk factors
pathology – micro
pathology – macro
presentation Some examples of cells processed with the Papanicolau stain
investigation
Cervical Screening
Swabs
If any ulcers, take swab from base of
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Title page
ulcer.
Cervical smear
methods
devices
If infection suspected, take swab from

Slide method
Swabs
cervix or high vaginal.
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
Undo the thumb screw
Jump menu
Title page
Cervical smear
Simultaneously withdraw the speculum
methods
devices
and rotate the open blades to ensure that
Slide method
the anterior and posterior walls of vagina
Swabs
Removing the speculum can be inspected.
Summary
Further reading Near the introitus, allow the blades to
Cervical Cancer
incidence
age
close
risk factors
pathology – micro Taking care not to pinch the labia or any
pathology – macro
presentation
investigation
hairs while withdrawing the speculum.
Cervical Screening
Tell the patient that you have
Jump menu
Title page
finished , give a towel to the patient

Cervical smear
methods
devices to wipe herself.
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
Send samples to lab
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
Summary
Jump menu Necessary equipment Wash hands, don gloves
Title page Cusco’
Cusco’s speculum Label bottle and open the lid
Speculum examination Cervix brush Assemble speculum
Specimen bottle

If not in warmer, warm under tap
Inspection of cervix Microbiology swabs
Cervical smear Water based lubricant Use fingers to keep blades shut
methods Tissues Warn patient
devices Introduce yourself Separate labia
Slide method
Identify patient (full name and DOB) Insert with rotating motion
Procedure – Avoid touching clitoris
Swabs
Explain what you are going to do and Under direct vision open the blades
what she may experience and angle the speculum accordingly
Permission so that cervix comes into view
Summary
Further reading
Obtain informed consent Inspect cervix and lateral vaginal
Privacy walls

Cervical Cancer
incidence Position Insert tip of cervex brush into os
age Heels together, draw heels towards Rotate 10X, sample whole cervix
risk factors
bottom, let knees flop apart Remove brush and dip vigorously into
pathology – micro
Light bottle
pathology – macro Exposure Remove the speculum gently, rotate
presentation Remove clothing from the waist to inspect anterior and posterior
investigation
down, cover with blanket vaginal walls
Cervical Screening Let the blades close carefully
Offer patient some tissues to wipe
herself, cover her with blanket and
leave the curtained area
Further Reading
Why screen regularly with smear
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Title page
test
Cervical smear
What is CIN ?
methods
devices
Slide method
What are the stages ?

Swabs
How do we treat ?
Summary
Further reading
How does CIN differ from invasive

Cervical Cancer
incidence
age
risk factors
pathology – micro
pathology – macro
cancer
presentation
investigation
Cervical Screening
Further reading
http://www.cancerscreening.nhs.uk/
Jump menu
Title page
cervical/publications/cervicalpocket2
Cervical smear
methods
devices 004.pdf
Slide method
Swabs
Summary
Further reading
http://www.gfmer.ch/Books/Cervical
Cervical Cancer
incidence _cancer_modules/Aided_visual_ins
age
risk factors
pathology – micro
pection_atlas.htm
pathology – macro
presentation
investigation
Cervical Screening
Cervical Screening
Jump menu
Title page General screening criteria
The disease should be responsible for

Cervical smear
methods
devices significant morbidity or mortality in the target
Slide method
Liquid-based cytology population
Swabs
Removing the speculum The natural history of the disease should be
Summary
known
Further reading
Cervical Cancer Intervention at an early stage should be
incidence
age
effective in preventing the condition
risk factors
pathology – micro A screening programme should be cost effective

pathology – macro
presentation Treatment should cause low morbidity
investigation
Cervical Screening
Cervical Screening
Almost four million women are
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Title page
screened each year
Cervical smear
methods
devices
42% fall in incidence of cervical

Slide method
Swabs
Ending the procedure cancer between 1988 and 1997
Summary
Further reading
Cervical Cancer
attributable to screening
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
Mortality rates in 2000 were 60%
investigation
Cervical Screening
lower than 30 years earlier
Cervical Screening
Jump menu
Title page
The screening programme in England and
Wales invites all women between 25 and 64
Inspection of cervix years for three- or five-yearly screening.
Cervical smear
methods
devices
Slide method It is recommended that women 25 to 49 are
Swabs
screened three-yearly and 50 to 64 five yearly.
Summary
Further reading
Women over 65 are only called if they have not
Cervical Cancer had a smear since age 50, or have had a recent
incidence
age
abnormality.
risk factors
pathology – micro
pathology – macro In Scotland the programme is slightly different, with women
presentation between the ages of 20 and 60 being invited for screening every
investigation
Cervical Screening
three years.
Cervical Intraepithelial
Neoplasia
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CIN I- Dysplasia in the basal 1/3

Title page
Cervical smear
CIN 2- Dysplasia extending to middles

methods
devices
Slide method
Swabs
1/3
Summary
Further reading
Cervical Cancer
CIN 3- Dysplasia involving the whole
incidence
age
epithelium but the basal membrane is
risk factors
pathology – micro intact.
pathology – macro
presentation
investigation Dysplasia
Cervical Screening
basal hyperplasia - multi-layering of basal cells
nuclear pleiomorphism
increased mitotic activity
Cervical Cancer
Jump menu
Title page
Incidence
Cervical smear
methods
devices 2400 new cases per year in England and
Slide method
Swabs
Wales
Summary
Further reading
Cervical Cancer
<1000 deaths annually
incidence
age
risk factors
½ of women who present with late stage

pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
disease have never had a smear
Cervical Cancer
Jump menu
Title page
Age
Cervical smear
Rare under 20yrs

methods
devices
Slide method
Swabs
Peak 45-55yrs
Summary
Further reading
Cervical Cancer
Peaks earlier in pts from lower
incidence
age socioeconomic groups
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
Cervical Cancer
Jump menu
Title page Risk factors
Age
Cervical smear
methods
Lower social class
devices
Slide method
HPV infection (types 16 and 18 mainly)
Swabs Large numbers of sexual partners
Partner with many previous partners
Smoking
Summary
Further reading
Cervical Cancer
incidence
age
Immunosuppression
risk factors
pathology – micro
Early age of 1st intercourse and 1st pregnancy
pathology – macro
presentation Abnormal smear
investigation
Cervical Screening Oral contraceptive use rather than barrier
Cervical Cancer
Jump menu
Title page
Pathology - micro
Cervical smear
80% squamous carcinoma of

methods
devices
Slide method
Swabs
transformation zone
Summary
Further reading
Rest are adenocarcinoma

Cervical Cancer
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
Cervical Cancer
Jump menu
Title page
Pathology – macro
Cervical smear
Ulceration or mass on cervix that

methods
devices
Slide method
Swabs
bleeds easily
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening
Cervical Cancer
Jump menu
Title page
Common Presentations
Cervical smear
methods
devices
Slide method
During routine smear
Swabs
Postcoital bleeding
Summary Intermenstrual bleeding
Postmenopausal bleeding
Further reading
Cervical Cancer
incidence
Offensive vaginal discharge

age
risk factors
pathology – micro
Pain
pathology – macro
presentation
investigation
Cervical Screening
Cervical Cancer
Jump menu
Title page Investigations
Urgent referral for colposcopy

Cervical smear
methods
devices
Slide method
Direct visualisation
Swabs
Green light – abnormal blood vessels
Acetic acid – causes coagulation of nuclear
Summary proteins, hence areas of high nuclear density
Further reading
Cervical Cancer
appear white
incidence
age
Iodine – Schiller’s test – abnormal immature
risk factors
pathology – micro
epithelium doesn’t contain glycogen and
pathology – macro therefore doesn’t stain with iodine
presentation
investigation
Cervical Screening
Other test
FBC
Jump menu
Title page
Cervical smear
U&E
methods
devices
Slide method
LFT
Swabs
Serum Ca
Summary Chest X-ray
CT scan
Further reading
Cervical Cancer
incidence
In advanced disease consider

age
risk factors
pathology – micro
cystoscopy / sigmoidoscopy
pathology – macro
presentation
investigation
Cervical Screening
Treatment
Jump menu
Title page
Depend on the stage of the disease
Cervical smear
Cone biopsy
methods
devices
Slide method Radical
Swabs
Hysterectomy
Summary
Further reading
Cervical Cancer
Radiotherapy Stage I-IV
Chemotherapy for some cases
incidence
age
risk factors
pathology – micro
pathology – macro
presentation
investigation
Cervical Screening

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Cervical speculum examination

 Able assemble the speculum

 Perform a cervical smear

 While inserting the instrument rotate it to

the speculum and press on the

 Adjust the light source to illuminate

 Asymptomatic discharge: gonorrhoea

Cervical polyp (appears to be descending through the os)

inspecting the cervix.

 Place the tip of the brush in the os

 Introduce the spatula through the

 Spread the cervical material onto the

should cling to the glass.

 Immediately spray the slides with

 If infection suspected, take swab from

finished , give a towel to the patient

 What are the stages ?

 How does CIN differ from invasive

 The disease should be responsible for

 42% fall in incidence of cervical

 CIN I- Dysplasia in the basal 1/3

 CIN 2- Dysplasia extending to middles

 ½ of women who present with late stage

 Rare under 20yrs

 80% squamous carcinoma of

 Rest are adenocarcinoma

 Ulceration or mass on cervix that

 Offensive vaginal discharge

 Urgent referral for colposcopy

 In advanced disease consider

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Able assemble the speculum

Perform a cervical smear

While inserting the instrument rotate it to

Adjust the light source to illuminate

Asymptomatic discharge: gonorrhoea

Place the tip of the brush in the os

Introduce the spatula through the

Spread the cervical material onto the

Immediately spray the slides with

If infection suspected, take swab from

What are the stages ?

How does CIN differ from invasive

The disease should be responsible for

42% fall in incidence of cervical

CIN I- Dysplasia in the basal 1/3

CIN 2- Dysplasia extending to middles

½ of women who present with late stage

Rare under 20yrs

80% squamous carcinoma of

Rest are adenocarcinoma

Ulceration or mass on cervix that

Offensive vaginal discharge

Urgent referral for colposcopy

In advanced disease consider