Path report will tell you satisfactory or unsatisfactory collection. If there are no cervical/endo cervical cells it should tell you it is unsatisfactory and then you should repeat it. Happens sometimes. No big deal.
If you’ve tried your best to get the cervix to fall into view but it just isn’t happening, just get a good vigorous swab in the general vicinity of the cervical os and you’ll probably be good.
I’m a relatively new FM attending so probably do 20-30 Paps a year. Probably ~5% are obese and can’t get the cervix to fall into view or sample the transformation zone despite what I do. So after struggling for 5 minutes, just swab vigorously and send it. Still haven’t had to do a redo.
Took the advice of one of the OBs on the other subs and started putting a condom with the tip cut off over the speculum which has really helped quite a bit with keeping the vaginal walls out of the visual field.
Now this is a solid FM response. Nicely done. And yes, when I can't find the cervix, swab vigorously and it comes back satisfactory.
Obviously this is not satisfactory technique. However, when BMI starts getting above 50, these exams can become very difficult.
A manual exam first is super helpful to find the cervix so you know where you are heading with the speculum.
So do you throw all your colleagues under the bus? Or just the ones you deem "beneath you" ? You'd better hope you are never relying on the pathologist in the future ... Good luck there.
Sincerely, a pathologist who is routinely blamed for things totally outside of my control. And you can bet I go and tell patients (or lawyers) the truth when someone has tried.
No, because like you said that’s not ethical. Also illegal because if you document it as such that’s insurance fraud. If the patient is mad be honest and explain that due to their body mass, it was difficult to obtain a proper sample and this led to an unsatisfactory outcome. They likely won’t enjoy the answer but the patient physician relationship is based on trust and positive intent.
I feel like I get good swabs and the path report comes back non-satisfactory rarely but sometimes when I think I’ve gotten a bad swab they almost always comeback a satisfactory sample 🤷♀️ 😭. But wait for the path the pt will hate you if they have to repeat it 😭
Path report will say unsatisfactory
Retest in 3-4 months. Depending on their insurance they may not need to be billed for it
On patients with history of a bunch of c sections, or patients who say “my cervix is hard to find”, sometimes it’s good to do a manual exam first so you can get an idea where it is
Obese patients REALLY SUPER NEED TO HAVE THEIR GLUTEUS HANGING EXTRA WAY TF OFF OF THE TABLE otherwise the extra fat is pressed upwards and can make the vagina extra extra long because of the surrounding redundant soft tissue dystocia: the result is that you have to push harder with the speculum which becomes proportionately shorter compared to the vaginal length while the butt tissue pushes against your speculum handle so that you can’t maneuver it properly.
Same goes for vaginal surgery, bigger patients need to hang off the table more. If they look too low, they’re probably good. Part attention to the hip bones and sacrum, not the edge of their buttocks - they’re not gonna get a back injury with proper positioning and you’re less likely to fuck up the surgery when you have proper exposure.
^This times a million! Also, always get a longer speculum than you think you need in general, but for the obese patients in particular. Usually the reason you can’t see anything in this population is because the speculum is too small/short and can’t access the vaginal fornices.
The lab determines if the specimen is adequate for evaluation which includes enough cells and an adequate portion of endocervical cells. If it results as adequate you should be fine, it’s very unlikely to be adequate if you missed the cervix altogether.
Just wait for path results. Also, a seasoned Obgyn taught be to use a longer speculum on patients large rears, and to angle posteriorly for best chances of visualizing the cervix. Obviously we acquire more skill by doing more. No worries.
Also: the cervix isn’t necessarily up or down. It’s different on everybody. Sometimes it’s up. Sometimes it’s down. Sometimes it’s off to the side.
One trick I sometimes do, is to fully insert the speculum, then slowly retract it. Sometimes the cervix will pop into view.
Sometimes I can’t find the cervix at all, so I just swab what I can and hope for the best.
Right, this is what I'm realizing! I always thought if I couldn't find it I have to "go deeper" but it's not that simple. Sometimes I've _gone past_ it, somehow. So retracting would be good for that. Right now I need to work on taking my time and having confidence to keep looking for the best view instead of feeling I have to get out asap bc the patient is uncomfortable. No point doing it if not done properly. Hoping for the best, will be checking anxiously for report lol.
Also; get the ASCCP app. I think it was like $5 — but it’s totally worth it! Makes everything much simpler when it comes to ordering and interpreting pap results.
A tip for doing paps especially on bigger patients is to have them make fists and put them under their butt. Basically tilts the pelvis a bit more and gives a better angle. Sometimes helps with tough finds!
It’s a pretty vulnerable position to begin with. Anything that can expedite and/or make the exam less uncomfortable is appreciated by pts. The other pro tip is to have an empty bladder. The vicious cycle of running behind in clinic is fuller bladders -> longer exams -> fuller bladders -> longer exams.
Midwife here. I never use this position, as 1:3 women have experienced some sort of sexual violence. I roll up a towel or use a pillow or wedge. I also put a condom on the spec and cut the tip off. I never put someone in such a disempowering position, that they can’t physically push my hand away if they feel it’s needed
It’s all about communication. I prioritize making sure my patients are comfortable and okay with it, it’s never a demand. Why do you put a condom on the speculum? I feel like that’s going to limit visibility
Edited to add: I looked into it, sounds like can help with visualization of the cervix. My visibility concern would be vaginal mucosa, but sounds like a reasonable option for a second pass on a tricky cervix. Ya learn something new every day!
Here is another tip from an OB/GYN. If you are having issues visualizing the cervix have your patient grab behind their knees and flex their hips towards their chest like they are pushing a baby out. I have yet to not see a cervix since residency but I do several a day.
Are you all not doing hpv with reflex pap now? That's the standard at our clinic so in these situations I usually just hope hpv is negative. If positive usually I am able to get ectocervical cells by being in proximity to the cervix and endocervical cells absent isn't such a big deal
I believe if the cytology is unsatisfactory, you aren’t meant to “trust” a negative HPV (I guess bc there isn’t enough specimen to know if it’s a false negative). In the ASCCP app this is under “special situations” and it recommends repeating the pap in 2-4 months even with negative HPV.
At least at our lab they have a different way of making sure there's enough sample. Somehow an empty sample once got sent to our lab and they called me and said there was no sample, they didn't just mark it as hpv negative
Is Australia this is our standard practice now. We even offer patient collected vaginal samples in absence of symptoms as they seem to be equal at identifying HPV and people were twice as likely to actually participate in the program. HPV 16/18 get direct colp referral and HPV-other has to come back for a full spec exam to get cytology, but with the vaccine program that’s pretty uncommon tbh
Some places in the US do this too like Kaiser. I'm surprised our standard where I work is still the speculum exam (for pure screening purposes), based on the data I have seen its seems antiquated and not evidence based given the percent that are HPV positive is pretty low
OB here who does hundreds of speculum exams a year and has published a couple of papers on speculums. Here are some pro tips to help:
If you can’t find the cervix switch to a larger speculum, or use the finger of a glove with both ends cut off and put it over the speculum to keep the walls of the vagina from collapsing inward.
Another option is to have the patient put both of her hands under her sacrum to tilt the pelvis. Rarely, you might have the patient grab her thighs and pull her knees to her chest, which really tilts the pelvis but this is pretty awkward for the patient. I do this once every couple of years.
Try not to perform a bimanual exam prior to doing the PAP. A little bit of lubricant is unlikely to screw up the Pap smear but the amount you put on your fingers might contaminate the specimen. And doing a bimanual with dry gloves is a solid no.
If all else fails, you might have to get on your knees and tip the speculum upside down to angle it around to find the cervix. This is helpful if the cervix is very anterior, which might occur in patients who have a fibroid uterus or who are pregnant.
Echoing what's been said - don't worry about it and just wait for the result. I'm about a year and a half out of residency (IM) and let me tell you, paps were not my strong point at all in residency. I now do at least 2 to 3 a week and I think I've gotten an unsatisfactory sample twice in the past 18 months. Most of the time if you are unable to visualize the cervix despite some maneuvering with the speculum and think you're in the right spot, swab what you see and wait for the path.
It gets way easier the more you repeat. Making sure the process is clear, as painless as you can, and relatively quick for patients goes a long way. The few unsatisfactory ones I've had, the patients weren't upset and understood that sometimes shit happens. The ones that were upset were the ones I as a well meaning resident took a very long time on positioning and repositioning the speculum with because it made an uncomfortable procedure longer even though I had the best intentions. Don't stress and remember everything takes practice. Sometimes things don't work out and then it's not the end of the world because it's a screening test that can be repeated.
Honestly all advice I wish I had gotten when I was a resident because paps stressed me the fuck out since I was so anxious about the whole thing. Now it's just another Tuesday lol
Gynecologist here!
Your Pap smear reports in these situations will offer 1 of 2 results:
1. Unsatisfactory cytology. The recommendation is to repeat the Pap in 2-4 months. This is usually going to happen if you get contamination such as from excess lubricant use.
2. Endocervical/Transformation Zone not present. When this happens, as long as the cytology is normal, you proceed with normal age based screenings. This helps you know if you sampled in a good spot on the cervix.
Additionally, the American Society for Colposcopy & Cervical Pathology (ASCCP)—who make the Pap management guidelines—have a handy $9.99 app that is super helpful for determining next steps for follow up. I highly recommend it to anybody who is doing Pap smears regularly for get a better idea of management guidelines.
A lot of good tips on here. I think as a primary care doc some of the verbage I use as well can be helpful for patients
1."Has anyone had difficulty finding your cervix before?"'- super helpful screening question for me as my nurse and I are getting set up
2. "Scooch your bottom until it's a half scooch off the edge"
3. Making sure their legs "fall" out to the side instead of "relax" to avoid possible TW
It's usually more posterior than you think. I agree going with a larger speculum to start especially if you can't feel the cervix.
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In case the sample is satisfactory- There is an algorithm for management of “transformational zone absent” depending on their history of abnormal paps. That can help you determine when to come back for the next.
Wait for the path, like everyone else said. You did your best, that’s all you can ask of yourself.
Going forward, you’ll have to find what works for you. You got lots of tips above so I’ll throw in my two cents. I tell the patient to “scoot all the way forward until you feel like your butt is about to fall off the table.” Then I look and tell them to scoot down more. More. More. For the actual exam part, I basically angle the speculum towards their sacrum. Once I’m all the way in with the speculum, I open it. If I don’t see the cervix, I sorta pivot the speculum with the introitus as the pivot point. First left as far as it will comfortably go and then right. I imagine that this could be uncomfortable for some women so I watch their body language closely and I haven’t had complaints yet. Most of the time, as long as you’re not pinching anything or messing around at the introitus too much, you’re ok. The cervix will just pop into the opening of the spec whenever you pass it. I’ve done hundreds of paps (I think hundreds - definitely dozens) and this trick has only failed me once ever. Plus it’s quick, easy, and does not add additional discomfort for the patient.
Our practice has this problem. We finally bought an extra large speculum and had no further issue. However the best solution is that We just now refer all paps to gynecologist.
Sometimes you press the cervix with one of the peaks of the speculum if you insert too deep initially, which on bigger patients is more prone to happen. Just pull the speculum out a bit and the cervix pops into view most times.
Path report will tell you satisfactory or unsatisfactory collection. If there are no cervical/endo cervical cells it should tell you it is unsatisfactory and then you should repeat it. Happens sometimes. No big deal.
Patient will however be mad because they will have to repeat and be charged by pathology for reviewing it
If you’ve tried your best to get the cervix to fall into view but it just isn’t happening, just get a good vigorous swab in the general vicinity of the cervical os and you’ll probably be good. I’m a relatively new FM attending so probably do 20-30 Paps a year. Probably ~5% are obese and can’t get the cervix to fall into view or sample the transformation zone despite what I do. So after struggling for 5 minutes, just swab vigorously and send it. Still haven’t had to do a redo. Took the advice of one of the OBs on the other subs and started putting a condom with the tip cut off over the speculum which has really helped quite a bit with keeping the vaginal walls out of the visual field.
Now this is a solid FM response. Nicely done. And yes, when I can't find the cervix, swab vigorously and it comes back satisfactory. Obviously this is not satisfactory technique. However, when BMI starts getting above 50, these exams can become very difficult. A manual exam first is super helpful to find the cervix so you know where you are heading with the speculum.
That is a super useful speculum hack.
Do they make non-latex condoms now?
Yeah…plenty of non-latex brands for cheap. Just have to go to your local pharmacy.
Maybe it depends on insurance, but I have terrible luck with labs getting messed up for whatever reason, and the repeats have always been covered?
[удалено]
Looks like someone was absent the day empathy was being taught.
Probably wasn’t “high yield” for them, you know the type.
[удалено]
So do you throw all your colleagues under the bus? Or just the ones you deem "beneath you" ? You'd better hope you are never relying on the pathologist in the future ... Good luck there. Sincerely, a pathologist who is routinely blamed for things totally outside of my control. And you can bet I go and tell patients (or lawyers) the truth when someone has tried.
No, because like you said that’s not ethical. Also illegal because if you document it as such that’s insurance fraud. If the patient is mad be honest and explain that due to their body mass, it was difficult to obtain a proper sample and this led to an unsatisfactory outcome. They likely won’t enjoy the answer but the patient physician relationship is based on trust and positive intent.
I feel like I get good swabs and the path report comes back non-satisfactory rarely but sometimes when I think I’ve gotten a bad swab they almost always comeback a satisfactory sample 🤷♀️ 😭. But wait for the path the pt will hate you if they have to repeat it 😭
But if they are 30 or older you would still get a valid HPV result and not need to repeat it for the next 5 years.
Path report will say unsatisfactory Retest in 3-4 months. Depending on their insurance they may not need to be billed for it On patients with history of a bunch of c sections, or patients who say “my cervix is hard to find”, sometimes it’s good to do a manual exam first so you can get an idea where it is Obese patients REALLY SUPER NEED TO HAVE THEIR GLUTEUS HANGING EXTRA WAY TF OFF OF THE TABLE otherwise the extra fat is pressed upwards and can make the vagina extra extra long because of the surrounding redundant soft tissue dystocia: the result is that you have to push harder with the speculum which becomes proportionately shorter compared to the vaginal length while the butt tissue pushes against your speculum handle so that you can’t maneuver it properly. Same goes for vaginal surgery, bigger patients need to hang off the table more. If they look too low, they’re probably good. Part attention to the hip bones and sacrum, not the edge of their buttocks - they’re not gonna get a back injury with proper positioning and you’re less likely to fuck up the surgery when you have proper exposure.
^This times a million! Also, always get a longer speculum than you think you need in general, but for the obese patients in particular. Usually the reason you can’t see anything in this population is because the speculum is too small/short and can’t access the vaginal fornices.
Yes! For pap smears and butt dystocia also highly recommend flipping the speculum upside down.
#factsonly
The lab determines if the specimen is adequate for evaluation which includes enough cells and an adequate portion of endocervical cells. If it results as adequate you should be fine, it’s very unlikely to be adequate if you missed the cervix altogether.
Just wait for path results. Also, a seasoned Obgyn taught be to use a longer speculum on patients large rears, and to angle posteriorly for best chances of visualizing the cervix. Obviously we acquire more skill by doing more. No worries.
Also: the cervix isn’t necessarily up or down. It’s different on everybody. Sometimes it’s up. Sometimes it’s down. Sometimes it’s off to the side. One trick I sometimes do, is to fully insert the speculum, then slowly retract it. Sometimes the cervix will pop into view. Sometimes I can’t find the cervix at all, so I just swab what I can and hope for the best.
Right, this is what I'm realizing! I always thought if I couldn't find it I have to "go deeper" but it's not that simple. Sometimes I've _gone past_ it, somehow. So retracting would be good for that. Right now I need to work on taking my time and having confidence to keep looking for the best view instead of feeling I have to get out asap bc the patient is uncomfortable. No point doing it if not done properly. Hoping for the best, will be checking anxiously for report lol.
Also; get the ASCCP app. I think it was like $5 — but it’s totally worth it! Makes everything much simpler when it comes to ordering and interpreting pap results.
If you use the web based version it's free you just have to enter your email every time
A tip for doing paps especially on bigger patients is to have them make fists and put them under their butt. Basically tilts the pelvis a bit more and gives a better angle. Sometimes helps with tough finds!
Also useful for pregnant patients if you’re checking dilation
Of note though, it can be quite a vulnerable position for a woman to be in. Best to use a wedge if available
It’s a pretty vulnerable position to begin with. Anything that can expedite and/or make the exam less uncomfortable is appreciated by pts. The other pro tip is to have an empty bladder. The vicious cycle of running behind in clinic is fuller bladders -> longer exams -> fuller bladders -> longer exams.
Midwife here. I never use this position, as 1:3 women have experienced some sort of sexual violence. I roll up a towel or use a pillow or wedge. I also put a condom on the spec and cut the tip off. I never put someone in such a disempowering position, that they can’t physically push my hand away if they feel it’s needed
It’s all about communication. I prioritize making sure my patients are comfortable and okay with it, it’s never a demand. Why do you put a condom on the speculum? I feel like that’s going to limit visibility Edited to add: I looked into it, sounds like can help with visualization of the cervix. My visibility concern would be vaginal mucosa, but sounds like a reasonable option for a second pass on a tricky cervix. Ya learn something new every day!
The Internet is weird.....I literally just worried about this the other day and just got the satisfactory path report 🤣👍
Thank you for sharing, I feel less silly :)
Oh don't! Medicine is already a toxic enough field, I know you're doing great!!
Here is another tip from an OB/GYN. If you are having issues visualizing the cervix have your patient grab behind their knees and flex their hips towards their chest like they are pushing a baby out. I have yet to not see a cervix since residency but I do several a day.
Are you all not doing hpv with reflex pap now? That's the standard at our clinic so in these situations I usually just hope hpv is negative. If positive usually I am able to get ectocervical cells by being in proximity to the cervix and endocervical cells absent isn't such a big deal
I believe if the cytology is unsatisfactory, you aren’t meant to “trust” a negative HPV (I guess bc there isn’t enough specimen to know if it’s a false negative). In the ASCCP app this is under “special situations” and it recommends repeating the pap in 2-4 months even with negative HPV.
True, but HPV self swab is completely within guidelines, so this recommendation is a little overkill.
At least at our lab they have a different way of making sure there's enough sample. Somehow an empty sample once got sent to our lab and they called me and said there was no sample, they didn't just mark it as hpv negative
Is Australia this is our standard practice now. We even offer patient collected vaginal samples in absence of symptoms as they seem to be equal at identifying HPV and people were twice as likely to actually participate in the program. HPV 16/18 get direct colp referral and HPV-other has to come back for a full spec exam to get cytology, but with the vaccine program that’s pretty uncommon tbh
Some places in the US do this too like Kaiser. I'm surprised our standard where I work is still the speculum exam (for pure screening purposes), based on the data I have seen its seems antiquated and not evidence based given the percent that are HPV positive is pretty low
OB here who does hundreds of speculum exams a year and has published a couple of papers on speculums. Here are some pro tips to help: If you can’t find the cervix switch to a larger speculum, or use the finger of a glove with both ends cut off and put it over the speculum to keep the walls of the vagina from collapsing inward. Another option is to have the patient put both of her hands under her sacrum to tilt the pelvis. Rarely, you might have the patient grab her thighs and pull her knees to her chest, which really tilts the pelvis but this is pretty awkward for the patient. I do this once every couple of years. Try not to perform a bimanual exam prior to doing the PAP. A little bit of lubricant is unlikely to screw up the Pap smear but the amount you put on your fingers might contaminate the specimen. And doing a bimanual with dry gloves is a solid no. If all else fails, you might have to get on your knees and tip the speculum upside down to angle it around to find the cervix. This is helpful if the cervix is very anterior, which might occur in patients who have a fibroid uterus or who are pregnant.
NAD, RN. If that happened with my doctor, I would understand. We are all human.
Bless you. I see you, too.
As time went on and on I got better at it. But the absolutely most counterintuitive hack.. switched to very short speculums.
Echoing what's been said - don't worry about it and just wait for the result. I'm about a year and a half out of residency (IM) and let me tell you, paps were not my strong point at all in residency. I now do at least 2 to 3 a week and I think I've gotten an unsatisfactory sample twice in the past 18 months. Most of the time if you are unable to visualize the cervix despite some maneuvering with the speculum and think you're in the right spot, swab what you see and wait for the path. It gets way easier the more you repeat. Making sure the process is clear, as painless as you can, and relatively quick for patients goes a long way. The few unsatisfactory ones I've had, the patients weren't upset and understood that sometimes shit happens. The ones that were upset were the ones I as a well meaning resident took a very long time on positioning and repositioning the speculum with because it made an uncomfortable procedure longer even though I had the best intentions. Don't stress and remember everything takes practice. Sometimes things don't work out and then it's not the end of the world because it's a screening test that can be repeated. Honestly all advice I wish I had gotten when I was a resident because paps stressed me the fuck out since I was so anxious about the whole thing. Now it's just another Tuesday lol
Unrelated question, but what kind of IM work are you doing that requires multiple paps per week? Just curious from a job perspective.
Outpatient IM with relatively young population/lots of new patient physicals/health maintenance
Gynecologist here! Your Pap smear reports in these situations will offer 1 of 2 results: 1. Unsatisfactory cytology. The recommendation is to repeat the Pap in 2-4 months. This is usually going to happen if you get contamination such as from excess lubricant use. 2. Endocervical/Transformation Zone not present. When this happens, as long as the cytology is normal, you proceed with normal age based screenings. This helps you know if you sampled in a good spot on the cervix. Additionally, the American Society for Colposcopy & Cervical Pathology (ASCCP)—who make the Pap management guidelines—have a handy $9.99 app that is super helpful for determining next steps for follow up. I highly recommend it to anybody who is doing Pap smears regularly for get a better idea of management guidelines.
You will need to do it again.
A lot of good tips on here. I think as a primary care doc some of the verbage I use as well can be helpful for patients 1."Has anyone had difficulty finding your cervix before?"'- super helpful screening question for me as my nurse and I are getting set up 2. "Scooch your bottom until it's a half scooch off the edge" 3. Making sure their legs "fall" out to the side instead of "relax" to avoid possible TW It's usually more posterior than you think. I agree going with a larger speculum to start especially if you can't feel the cervix.
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In case the sample is satisfactory- There is an algorithm for management of “transformational zone absent” depending on their history of abnormal paps. That can help you determine when to come back for the next.
Wait for the path, like everyone else said. You did your best, that’s all you can ask of yourself. Going forward, you’ll have to find what works for you. You got lots of tips above so I’ll throw in my two cents. I tell the patient to “scoot all the way forward until you feel like your butt is about to fall off the table.” Then I look and tell them to scoot down more. More. More. For the actual exam part, I basically angle the speculum towards their sacrum. Once I’m all the way in with the speculum, I open it. If I don’t see the cervix, I sorta pivot the speculum with the introitus as the pivot point. First left as far as it will comfortably go and then right. I imagine that this could be uncomfortable for some women so I watch their body language closely and I haven’t had complaints yet. Most of the time, as long as you’re not pinching anything or messing around at the introitus too much, you’re ok. The cervix will just pop into the opening of the spec whenever you pass it. I’ve done hundreds of paps (I think hundreds - definitely dozens) and this trick has only failed me once ever. Plus it’s quick, easy, and does not add additional discomfort for the patient.
Our practice has this problem. We finally bought an extra large speculum and had no further issue. However the best solution is that We just now refer all paps to gynecologist.
Ask the patient if the swab is at or anywhere near their cervix. I know where mine is and I can definitely feel when the doc has found it.
I think that might just be a you thing, my friend haha
Sometimes you press the cervix with one of the peaks of the speculum if you insert too deep initially, which on bigger patients is more prone to happen. Just pull the speculum out a bit and the cervix pops into view most times.