Genital examination — female

Indicators for genital and speculum examination include

  • Cervical Screening

    • Done as population screening or follow up as per national guidelines

    • Cervical screening requires collection of HPV samples. This can be done via speculum examination or lower vaginal swab (LVS)
  • STI check
    • Done if symptomatic or as part of population screening
    • Can be done as part of speculum examination but usually by self-collected LVS
  • Investigation of vaginal bleeding — pregnant and non-pregnant women
  • Assessment of pregnancy complications

Ask

  • Any current vaginal bleeding
    • Encourage cervical screening (if due) even if woman has her period
    • If bleeding irregular or symptoms of infection — important to do cervical screening now to help make early diagnosis
    • If bleeding abnormal strongly advise speculum exam and request HPV+LBC co-test
  • Menstrual history
    • Last menstrual period
    • Menstrual pattern — cycle length, duration and amount of flow, any pain
    • Any bleeding between cycles
  • Vaginal discharge, itching, soreness
  • Pain on passing urine
  • Any urinary or faecal incontinence
  • Any genital sores, rash or lump
  • Lower abdominal pain or pain with sex
  • Contraception — check if happy with current method, any concerns
  • Sexual partner/s — regular or casual

Do

Speculum examination

  • Explain and demonstrate what is involved in a speculum examination
    • Be specific. Show equipment and use pictures to explain procedure
    • Explain that the procedure should not be painful but may be uncomfortable. Woman can stop procedure at any time
    • Explain that there may be some vaginal spotting or light bleeding after procedure
    • Ask ATSIHP to help explain and translate if appropriate
  • Find out whether woman would like someone with her even if practitioner female. Record whether support person present
  • Ask woman to empty her bladder — if appropriate collect sample for U/A, pregnancy test, STI screen
  • Inspect vulva, perineum and anal area for warts, sores, discharge, unusual skin conditions — see genital ulcers and lumps
  • If painful unhealed sores around vaginal opening that could be genital herpes — do not continue with speculum examination 
  • Put in speculum and inspect vagina walls and cervix for
    • Polyps, warts, ulcers, abnormal appearance
    • Discharge — colour and amount
    • Cervicitis (inflammation of cervix) — cervix bleeds easily when touched
    • Ectropion — normal finding, red velvety area on outside of cervix extending into canal, sharp edge
  • Collect cervical screening sample and STI swabs as needed — see collecting samples
  • Bimanual examination if needed and skilled to perform
  • Test pelvic floor muscle tone if needed
    • Ask woman to tighten muscles around your fingers for as long as she can. Muscles should lift upward
    • If muscles seem weak or slack — pelvic floor exercises

Follow-up

  • Talk with woman about coming back for results and how long results will take to arrive
  • See Managing results
  • Medical consult about any abnormal findings

Clinician-collected samples

Swabs for STI tests

What you need

  • Aptima swab or dry swab (flocked if available) for NAAT​ — labelled HVS/ECS (high vaginal swab/endocervical swab)  
  • 1 Amies transport medium swab for gonorrhoea culture and MC&S — labelled HVS/ECS

What you do

Using Aptima/dry swab

  • Collect sample from just inside cervical canal — Figure 6.5 position 1
  • THEN use same swab to collect sample from high (deep) in vagina (in posterior fornix below cervix) — Figure 6.5 position 2
  • If using Aptima swab — take care not to touch swab below groove
    • Remove lid from tube and put swab in tube — Figure 6.6
    • Break off handle at groove — Figure 6.7 leaving swab in tube
  • ​If using plain dry swab — put back into transport tube

Figure 6.5   

Repeat procedure with Amies transport medium swab

  • Put swab into Amies transport medium container

Figure 6.6   

Figure 6.7   
  • Make sure swab containers correctly labelled, closed tightly
  • Store and transport at room temperature

Request

  • Aptima/dry swab — ​​HVS/ECS – gonorrhoea​​, chlamydia​​, trichomonas NAAT
  • Amies transport medium swab — HVS/ECS – MC&S ​and gonorrhoea culture

Cervical Screening

  • Screening test for HPV infection and cervical changes that may lead to cervical cancer
  • Cervical Screening — primary HPV test with LBC if needed

Best time to take cervical screening

  • Bleeding not a reason to delay
  • Best taken between periods and when no significant cervical infection
  • For older women vaginal dryness can make taking cervical screening uncomfortable and more difficult
    • Give local oestrogen preparation for 2 weeks before screening. Will not affect the HPV test, reflex LBC cell quality will be improved
  • In pregnancy
    • Best done before 24 weeks if due
    • Medical consult if concerned
    • Postnatal cervical screening best collected at or after 6 weeks. Can be done earlier if needed

Attention

  • Need to sample cells from the cervical Transformation Zone (TZ) — where red endocervical cells change to paler ectocervical cells
  •  Shorter bristles should cross TZ
  • If they dont cross TZ
    • Because of large ectropion – can use spatula as well to collect TZ and ectocervix sample
    • Because TZ not visible – can use endocervical brush as well to collect TZ and endocervix sample
    • Outside cervical canal and easily seen — usual in premenopausal women
    • Inside cervical canal and not visible — common in postmenopausal women
  • Area of visible endocervical cells is called ectropion. Amount visible depends on age and hormonal status of woman

Figure 6.8   

What you need

  • Speculum
  • Water based lubricant
  • Examination light
  • Liquid based cytology (LBC) vial (eg Thinprep, SurePath) labelled with woman’s name, date of birth
  • Choice of sampling tool/s
    • Cervix sampler 'broom' — preferred tool for cervical screening
    • Plastic spatula (do not use wooden spatula)
    • Endocervical brush (eg Cytobrush). Do not use in pregnancy
  • Pathology request form, include indications for screening in clinical notes section of form

What you do

  • Have all equipment ready and label vial before starting
  • Cervical sample must include material from the transformation zone — see Figure 6.8
  • Tools
    • Usually use cervix sampler 'broom',  less commonly use plastic spatula and endocervical brush
    • Endocervical brush may be helpful if TZ not visible and inside the cervical canal (do not use in pregnancy)
  • If pregnant —
    • Do not use endocervical brush — use broom or plastic spatula
    • AND any concerns about doing cervical screening (eg history of miscarriage) — medical consult
  • Cervix sampler (broom) — Figure 6.9
    • Put long central bristles just inside cervical opening so shorter bristles rest on outer cervix — Figure 6.10
    • Rotate through 360° 5–6 times in same direction
    • Shorter bristles should cross TZ 
    • If TZ and ectocervix not visible due to large ectropion, use plastic spatula and endocervical brush to collect TZ, endocervix and ectocervix samples

Figure 6.9   

Figure 6.10   
  • Plastic spatula — Figure 6.11
    • Rest spatula firmly on cervix with elongated end in cervical os
    • Rotate through 360° twice in same direction — Figure 6.12
    • Use endocervical brush as well to collect TZ and endocervix sample

Figure 6.11   

Figure 6.12   
  • Endocervical brush (eg Cytobrush) — Figure 6.13
    • Put endocervical brush gently into cervical opening for ⅔ of length, with last 2 rows of bristles still seen — Figure 6.14
    • Do ¼ (90°) turn of brush — may cause a little bleeding

Figure 6.13   

Figure 6.14   
After taking sample for cervical screening
  • Before removing speculum quickly transfer cervical sample from tool (broom, brush or spatula) to vial containing liquid based medium
  • Agitate end of cervix sampler broom, endocervical brush or spatula in the liquid-based cytology ​solution — Figure 6.15
    • If using Thinprep — throw away instrument
    • If using SurePath — leave tips of broom/brush in the solution
  • Tighten lid on container so marks on lid and vial meet up
  • Now remove speculum
  • Give information on pathology form to help interpret test eg pregnant, last cervical screen result if available, examination findings, contraception, date of last normal menstrual period, postmenopausal, taking HRT, if cervix clearly viewed
  • Test of Cure
    • If taking cervical sample for follow-up after treatment of a HSIL abnormality — request HVP+LBC co-test. Both needed for Test of Cure
    • Include clinical indication for co-test (eg previous HSIL) and date of treatment if known
  • Abnormal bleeding at time of a cervical screening
    • If woman has abnormal vaginal bleeding at time cervical sample collected — request HPV+LBC co-test
    • Include clinical indication for co-test on pathology form ie abnormal bleeding

Figure 6.15   

Self-collected samples
  • STI check – see LVS
  • Cervical screening – LVS sample
    • LVS samples for cervical screening can be collected by the woman or the clinician

LVS for HPV test for cervical screening

Use flocked swab (eg FLOQ) provided by laboratory. Swab must be turned multiple times to collect an adequate sample

Instructions for woman

  • Take swab out of packet/container (numbered 3 if multiple tests)
  • Put tip of swab about 2–4cm (length of 1–2 finger joint) inside vagina — Figure 6.16
    • Turn swab around vagina 6–8 times, remove
  • Put swab back into packet/container
  • Wash her hands, return swab to nurse or ATSIHP

Figure 6.16  

When woman returns swab

  • If swab given to woman in packet — take out and put into transport medium tube
  • If swab given to woman in container — make sure swab in tube and cap on
  • On request form must write either self collected HPV test OR clinician collected HPV test
    • Give information on pathology form to help interpret test eg pregnant, last cervical screen result if available, contraception, date of last normal menstrual period, postmenopausal, taking HRT
  • Make sure swab container correctly labelled, closed tightly
  • Store and transport at room temperature

Supporting resources

  • Cancer Council Australia national cervical cancer screening guidelines
  • Self-collection instructions for a HPV test sample