Introduce yourself, confirm the patient's name and date of birth.
Ask the patient if they have had a speculum examination or a cervical smear before and whether they understand what it involves. Explain the purpose of the examination and obtain consent. Inform the patient that the examination may be slightly uncomfortable, but if they feel any pain that they should let you know. Always call for a female chaperone. Ask the patient if they would like to empty their bladder before beginning.
Before proceeding, ask the patient if they are in any pain or discomfort.
Knowing what to say in a speculum examination and cervical smear is important. Here are a few recommended phrases:
“I have been asked to perform a speculum examination. Have you had one before? Do you understand what it involves?”
“In this examination, I will be inserting a device called a speculum into your vagina to enable me to check your cervix. I will also use a very small brush to take a sample of cells from the neck of your womb. The examination should not be painful, but it may feel slightly uncomfortable.”
Positioning and exposure
The patient must be exposed below the waist, including removal of any undergarments. Ask the patient to get themselves ready, lie down on the bed, and cover themselves with the sheet provided. Close the curtains to give the patient privacy.
Once the patient is ready ask them to lie supine on the bed, put their feet together, bring their heels towards their bottom and slowly part their knees. This is known as the lithotomy position.
Remember the 7 C's:
Confirm (name and DOB), consent, check understanding, chaperone, behind the curtains, lie down on the couch (bed) and cover to preserve dignity.
Whilst the patient is preparing, wash your hands and obtain the following:
A pair of non-sterile gloves.
There are many types of vaginal specula, and it is important to have the correct size. The “Cusco's” speculum is commonly used in the UK and is 80mm long and 22mm broad. Smaller and larger sizes are available. If the standard speculum appears to be too small or large, simple start over with the appropriate size.
Begin the examination with a general inspection of the perineum and surrounding area.
Ask the patient if they are in pain and are comfortable. Remove the covering sheet and inspect the vulva. Look for any scarring, which can be from previous surgery, and ulceration, which could be due to an infection such as herpes simplex virus. Inspect for masses such as Bartholin’s cyst, and for any varicosities (more common with age), abnormal bleeding or discharge. Vaginal atrophy may be visible, and this is common in menopause.
Ask the patient to cough. This may reveal a bulge from the vagina, an indication of a prolapse, or exacerbate any discharge or bleeding that was otherwise not visible.
Stay alert for subtle signs. For example, an obviously offensive smell is sometimes missed out by students. This, in association with discharge, suggests infective diagnoses such as bacterial vaginosis.
The two Bartholin’s glands are situated behind the labia minora and are responsible for secreting lubricating mucus for coitus. There may be blockage of these glands which leads to cyst formation, often visible as a mass on inspection of the vulva.
There may be numerous causes for visible abnormal bleeding on inspection. This may be infection (pelvic inflammatory disease), fibroids, cysts, miscarriage or malignancy.
Bacterial vaginosis: An infection of the vagina, most commonly caused by Gardnerella vaginalis. It presents with thin, white homogenous discharge, with an offensive fishy odour.
Trichomonas vaginalis: Trichomonas vaginalis is a motile, flagellated protozoan parasite. Characteristic features of trichomoniasis include a yellow/green, offensive, frothy discharge and a strawberry cervix.
Candida: Also known as vaginal candidiasis or vaginal yeast infection, vaginal thrush is caused by the fungus Candida. Characteristic features include itchiness and a ‘cottage cheese’ discharge.
Apply some lubricant jelly to the sides of the speculum blade. Avoid applying jelly to the tip of the speculum as this can interfere with the smear. Unscrew the speculum fully and move slightly to the patient’s right side.
Before proceeding, warn the patient that you are about to insert the speculum. Using your index finger and thumb of your left hand, gently part the labia. Using your right hand hold the speculum sideways at a 90o, make sure the blades are closed. Gently insert the speculum into the vagina. As you so do, slowly rotate the device 90o so that the handle is facing upwards. Open the blades until you are able to visualise the cervix. Tighten the screw to lock the open speculum.
Inspect the cervix. Identify the cervical os, which in normal instances, should be closed. An open cervical os is most commonly associated with miscarriages before 24 weeks gestation.
Inspect for any signs of redness around the os which is indicative of a cervical ectropion. Check for active bleeding or discharge.
Threatened miscarriage: Painless vaginal bleeding; cervical os is closed.
Missed miscarriage: A gestational sac containing products dead products of conception before 20 weeks without any symptoms of expulsion. There may be light vaginal bleeding or discharge; cervical os is closed.
Inevitable miscarriage: Heavy bleeding which is painful; cervical os is open.
Incomplete miscarriage: Bleeding with pain. Not all products have been expelled; cervical os is open.
This occur due to the process of eversion when the columnar epithelium of the endocervix is visible on the surface of the os as a red area. It is a normal finding in younger women, particularly in those who are taking the oral contraceptive pill and those who are pregnant.
Gently insert the endocervical brush through the speculum ensuring it does not touch the speculum walls. The tip of the brush should come into contact with the cervical os. Rotate the brush five times in a clockwise direction. Slowly remove the brush and place the tip of the brush into the sample pot container for liquid-based cytology.
Unscrew the speculum and slowly remove it by rotating it 90 degrees. Do not fully close the blades in order to avoid trauma to the cervix or walls of the vagina.
The NHS cervical screening programme screens for cytological abnormalities to help prevent cervical cancer. A cervical smear is offered at routine intervals to all women between the ages of 24.5 and 64. The frequency of screening depends on the age of the patient as follows:
24.5 years: Patient is invited to have their first cervical smear.
25 – 49 years: Patient is screened every 3 years.
50 – 64 years: Patient is screened every 5 years.
65+ years: Patient is screened if recent cervical cytology has been abnormal, or, if the patient has not had any screening since the age of 50 and they request one.
The results of a smear may be reported as normal, inadequate or abnormal. If normal, then the patient is returned to routine screening. If inadequate, the smear should be repeated within 3 months.
Abnormal smear cytology results point to premalignant disease of the cervix or cancer itself. The management depends on the nature of the result.
If the abnormal result is described as borderline or low-grade dyskaryosis then a high-risk human papilloma virus (HR-HPV) test should be performed. If negative, then the patient is returned to routine screening. If positive, they should be referred for colposcopy within 6 weeks.
If the abnormal result is described as high-grade dyskaryosis, or there is suspected invasive carcinoma or glandular neoplasia, then the patient should be referred for colposcopy within 2 weeks.
Provide the patient with paper towels and allow them to re-dress behind the curtains. Thank the patient, remove your gloves and dispose of them into a clinical waste bin. Wash your hands.
Complete your examination by labelling the sample pot with the patients details and document your procedure in the patient’s medical notes. Next offer to perform a bimanual examination, abdominal examination, and microbiology swabs if indicated.
When assessing each other, click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end. We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
Introduction: “Hello, I’m SimpleOSCE and I am a medical student. I have been asked to perform a speculum examination and cervical smear today? Can I confirm your name and DOB? Thank you.”
Explain the examination and obtain consent.
"For the purpose of this examination the examiner will act as a chaperone."
Position the bed flat and ensure adequate exposure.
Correctly place the patient in the lithotomy position.
Gather the appropriate equipment (gloves, lubricant, speculum, endocervical brush, sample pot and paper towels).
Wash your hands.
Ask about pain and discomfort.
Inspect the patient and their surroundings.
Inspect the vulva for scarring, masses, cysts and discharge.
Apply lubricant jelly to the speculum.
Warn the patient before inserting the speculum.
Insert the speculum horizontally and rotate 90° until the cervix is visible.
Inspect the cervical os for patency, redness, active bleeding or discharge.
Insert the endocervical brush and correctly take a smear, rotating the brush 5 times in a clockwise direction.
Deposit the tip of the brush in the sample pot for liquid-based cytology.
Carefully remove the speculum.
Thank and cover up the patient.
Give the patient privacy to re-dress and wash hands.
Label the sample pot correctly with patient details.
"To conclude, I would like to take a full history, perform a bimanual and abdominal examination.”