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APGOClinicalSkillsCurriculum

CervicalCytology,

WetPrepandCervical

CultureCollection

AssociationofProfessorsofGynecologyandObstetrics(APGO)

UndergraduateMedicalEducationCommittee2008

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CervicalCytology,WetPrep

andCervicalCultureCollection

TableofContents

IntendedLearningOutcomes 3

DescriptionoftheCervicalCytology,WetPrepandCervical/

VaginalCultureCollectionProcedure 4

BestPractices 9

Checklist

10

PerformanceAssessment 11

PracticalTips 13

Resources 13

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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)years solongasitremainsnormal.IfHPVtesting,riskprofileandcytologyis

negative,thencombinedscreeningshouldberepeatednomorethaneverythreeyears.

Ifthereisnohistoryofcervicalabnormalities,thepatientandclinicianmaydecideto

discontinuescreeningcytologyatage6570yearsorfollowingahysterectomy(for

benignindications).

Thecollectionofcervical/vaginalmaterialforculturesandwetprepisgenerallydoneforaspecificindication,suchasvaginitisorforscreeningforsexuallytransmitted

infections.Variousvaginalconditions,includingvulvovaginalcandidiasis,bacterial

vaginosis,trichomoniasisandleukocytosis,canbevisualizedonwetprep.

Thecervicalcytologyscreeningvisitisalsoanopportunitytoaddressandcounsel

patientsonvariousadditionalissues.

Thelearningobjectivesofcervicalcytologycollectionareto:

1.

Demonstrate

understanding

of

the

background,

technique

and

interpretation

of

traditionalslideandliquidbasedcervicalcytology

2. Demonstratetheappropriatetechniqueincollectingcervicalcytology

3. Describethescreeningintervalsindifferentagegroups

4. Counselpatientsappropriatelyabouttheroleofcervicalcytologyinthe

detectionofcervicalcanceranddysplasia

5. Communicatewiththepatientinarespectful,sensitivemannerduringthe

examination

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LiquidBasedCytologyCollection:

9. Studentshouldfirstusetheplastic(notwood)spatulatocollectectocervicalcells

(rotate360degrees),thenbrushlikedevice(rotate180degrees)tocollect

endocervicalcells.Onlyinsertbrushsuperficiallyinpregnancy.

10.

Bothspatulaandbrushshouldbesweptaroundtheinsideoftheliquidbased

cytologyspecimencollectioncontainer10timestoloosenthemaximumnumber

ofcervicalcellsintosolution.

11.Thestudentorassistantshouldlabelthecontainerappropriately.

TraditionalCytologySmearCollection TraditionalSlidePreparation

LiquidBasedCytology LiquidCytologyPreparation

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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

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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

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BestPractices

Wefoundthatmoststudentsareintroducedtothesebasicskillsduringclinicalskills

courses.Insomeinstances,opportunitiestoperformtheseskillsongynecologicexam

instructorsorstandardizedpatientswouldfollow.Thereiscurrentlyadearthof

simulationtypeorWebbasedopportunitiestopracticetheseskillsoutsidetheclinical

arena.Moststudentsgainthemajorityofopportunitiestoperformtheskillsduringtheir

clinicalclerkshipintheformofsupervisedclinicalcontact.

Aninformalsurveyof17medicalschoolsaroundthecountryconfirmedthesefindings.

Weprovidethefollowingmaterialstohelpstandardizetheinstructionandevaluation

processinamannerconsistentwiththebestpracticesofacademicinstitutionsacrossthe

country.

Thereforewesuggestintroducinginstructionofcytology,cervicalculturecollectionand

wet

prep

as

a

simulation

using

a

pelvic

model

and

prepared

slides

of

wet

prep

findings,

andthensupplementingclinicalexperienceduringtheObstetricsandGynecology

clerkshipwithstandardizedpatientexperience.

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Checklist

Well

Done

Needs

Improvement

Not

Done

Cannot

Recall

GeneralApproachand

CommunicationSkills

Properlyintroducedhim orherself

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

Insertedthespeculumcorrectlyandvisualizedthecervix

Usedtheappropriatecollectionvial

forthespecimen

Foracervicalculture,placedthe

swabintheendocervixfor10

seconds

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Foravaginalculture,obtained

specimenfromtheposteriorvaginal

fornix

Cappedoffandlabeledspecimen

appropriately

Preparedslideforwetprepcorrectly

Correctlyidentifiedyeast,cluecells,

trichomonas,squamouscellsand

whitebloodcells,ifpresent

Appropriatelydiscussedfindings

andtreatmentwithsupervising

clinician

GlobalAssessment

Studentsoverallperformancewas:

Excellent VeryGood Good Fair Poor

PerformanceAssessment

Thecervicalcytologyandcervical/vaginalculturecollectionskillsarebestassessed

throughdirectobservationofeitheraclinicalencounter,astandardizedpatient

encounterorsimulatedsessionusingapelvicmodel.Thewetprepcollectionand

interpretationskillsarebestassessedusingvaginalfluid,ifavailable,orothersimilar

material(suchashandlotion).Ifthelatterisused,thestudentshouldhaveaccessto

preparedslidesdemonstratingthefindingscommonlyseenonawetprep,suchascluecells,whitecells,trichomonadsorhyphae.

Theprecedingchecklistcanbeusedforperformanceassessmentofaclinicalencounter.

Belowisacasescenario,whichcanbeusedforstandardizedpatientstation,followedby

anexampleofapostencounternote,ifdesired(modeledafterUSMLEClinicalSkills

Exam).

InstructionsfortheCervicalCytology,Cultures,WetPrepStation

This

station

is

30

minutes

in

length.

The

first

15

minutes

are

spent

interviewing

the

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:BP120/80P70/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

2.Bacterialvaginosis

3.Physiologicdischarge

4.

5.

DiagnosticWorkup:Listimmediate

plans(upto5)forfurtherdiagnostic

workup:

1.Wetprep

2.CervicalcytologywithreflexHPV

testing

3.HPVvaccine

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.

http://www.asccp.org/http://www.asccp.org/