Papanicolaou Test

The Papanicolaou (Pap) test is a widely known cytologic test for early detection of cervical cancer. A doctor or specially trained nurse scrapes secretions from the patient's cervix and spreads them on a slide, which is sent to the laboratory for cytologic analysis. The test relies on the ready exfoliation of malignant cells from the cervix and shows cell maturity, metabolic activity, and morphology variations.

Although cervical scrapings are the most common test specimen, the test may involve cytologic evaluation of the vaginal pool, prostatic secretions, urine, gastric secretions, cavity fluids, bronchial aspirations, sputum, or solid tumor cells obtained by fine needle aspiration. If a Pap test is positive or suggests malignancy, cervical biopsy can confirm diagnosis.

Purpose

• To detect malignant cells
• To detect inflammatory tissue changes
• To assess response to chemotherapy and radiation therapy
• To detect viral, fungal and, occasionally, parasitic invasion

Patient preparation

• Explain to the patient that the test allows the study of cervical cells.
• Stress its importance as an aid for detection of cancer at a stage when the disease is often asymptomatic and still curable.
• The test should not be scheduled during the menstrual period; the best time is mid-cycle.
• Instruct the patient not to douche or insert vaginal medications for 24 hours before the test because doing so can wash away cellular deposits and change the vaginal pH.
• Tell her the test requires that the cervix be scraped, who will perform the procedure and when, and that she may experience slight discomfort but no pain from the speculum.
• Inform her that the procedure takes 5 to 10 minutes or slightly longer if the vagina, pelvic cavity, and rectum are examined bimanually.
• Obtain an accurate patient history, and ask the following questions: When did you last have a Pap test? Have you ever had an abnormal Pap test? When was your last menstrual period? Are your periods regular? How many days do they last? Is bleeding heavy or light? Have you taken or are you presently taking hormones or oral contraceptives? Do you use an intrauterine device? Do you have any vaginal discharge, pain, or itching? Which, if any, gynecologic disorders have occurred in your family? Have you ever had gynecologic surgery, chemotherapy, or radiation therapy? If so, describe it fully. Note any pertinent patient history data on the laboratory slip.
• Provide emotional support if the patient is anxious; tell her that test results should be available in a few days.
• Ask the patient to empty her bladder just before the test.

Equipment

Gloves; drape; vaginal speculum; collection device, such as a Pap stick (wooden spatula), cotton-tipped swab, or clean, dry glass pipette with rubber bulb; saline solution; glass microscopic slides; fixative (commercial spray or 95% ethyl alcohol solution in a jar) for slides.

Procedure and posttest care

• Instruct the patient to disrobe from the waist down and to drape herself.
• Ask her to lie on the examining table and to place her heels in the stirrups. (She may be more comfortable if she keeps her shoes on.) Tell her to slide her buttocks to the edge of the table. Adjust the drape to minimize exposure.
• To avoid startling the patient, tell her when the examination will begin.
• The examiner puts on gloves and inserts an unlubricated speculum into the vagina. To make insertion easier, the speculum may be moistened with saline solution or warm water.
• After the examiner locates the cervix, he collects secretions from the cervix and material from the endocervical canal with a saline-moistened cotton-tipped swab or wooden spatula.
• He then spreads the specimen on the slide according to laboratory recommendations and immediately immerses the slide in (or sprays it with) a fixative.
• Alternatively, posterior vaginal pool secretions and pancervical material may be collected and smeared on a single slide, which must be fixed immediately according to laboratory instructions.
• Label the specimen appropriately, including the date, the patient's name, age, the date of her last menstrual period, and the collection site and method.
• A bimanual examination may follow removal of the speculum. Help the patient up and instruct her to dress when the examination is completed.
• Supply the patient with a sanitary napkin if cervical bleeding occurs.
• Tell the patient when to return for her next Pap test.

Precautions

• Make sure that the cervical specimen is aspirated and scraped from the cervix. Aspiration of the posterior fornix of the vagina can supplement a cervical specimen but should not replace it
• Scrapings taken directly from the lesion are preferred if vaginal or vulval lesions are present.
• Use a small pipette, if necessary, in a patient whose uterus is involuting or atrophying from age, to aspirate cells from the squamocolumnar junction and the cervical canal.
• Preserve the slides immediately.

Normal Findings

Normally, no malignant cells or other abnormalities are present.

Abnormal findings

Malignant cells usually have relatively large nuclei and only small amounts of cytoplasm. They show abnormal nuclear chromatin patterns and marked variation in size, shape, and staining properties and may have prominent
nucleoli.

A Pap smear may be graded in different ways, so check your laboratory's reporting format. The following list contains the traditional classifications:

• Class l: normal pattern; absence of atypical or abnormal cells
• Class II: benign abnormality; atypical, but nonmalignant, cells present
• Class III: atypical cells consistent with dysplasia
• Class IV: suggestive of, but inconclusive for, malignancy
• Class v: conclusive for malignancy.

To confirm a suggestive or positive cytology report, the test may be repeated or followed by a biopsy.

Interfering factors

• Douching before the test (can wash away cellular deposits)
• Excessive use of lubricating jelly on the speculum
• Collection of the specimen during menstruation
• Exclusive use of a specimen collected from the vaginal fornix (possible false-negative)
• Delay in fixing the specimen (difficult cytologic interpretation due to dehydration of cells)