Cervical Screening Test (Smear Test) – OSCE Guide


Cervical screening (previously known as a smear test) frequently appears in OSCEs and you’ll be expected to demonstrate excellent communication and practical skills. This guide provides a step-by-step approach to performing cervical screening in an OSCE setting, with an included video demonstration.


Introduction

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain what the procedure will involve using patient-friendly language: “Today I need to perform a cervical screening test. The procedure will involve me inserting a small plastic device called a speculum into the vagina. This will allow me to visualise the neck of the womb. I will then place a very small brush into the vagina and take a sample of cells from the neck of the womb. It shouldn’t be painful, but it will feel a little uncomfortable. You can ask me to stop at any point. You may experience some light vaginal bleeding after the procedure.”

Explain the need for a chaperone: “One of the female ward staff members will be present throughout the examination, acting as a chaperone, would that be ok?”

Gain consent to proceed with the examination: “Do you understand everything I’ve said? Do you have any questions? Are you happy for me to carry out the procedure?”

Ask the patient if they have any pain or if they think they may be pregnant before proceeding with the clinical examination.

Provide the patient with the opportunity to pass urine before the examination.

Explain to the patient that they’ll need to remove their underwear and lie on the clinical examination couch, covering themselves with the sheet provided. Provide the patient with privacy to undress and check it is ok to re-enter the room before doing so.

Wash your hands.

  • Wash hands
    Wash your hands

Gather equipment

  • Gloves
  • Lubricant
  • Speculum
  • A light source for the speculum
  • Endocervical brush
  • Sample pot (liquid-based cytology)
  • Paper towels
  • Cervical smear equipment
    Gather equipment

Inspection

Position

1. Don a pair of non-sterile gloves.

2. Position the patient in the modified lithotomy position: “Bring your heels towards your bottom and then let your knees fall to the sides.”

  • Vaginal examination
    Position the patient supine

Inspect the vulva

1. Inspect the vulva for abnormalities:

  • Ulcers: typically associated with genital herpes.
  • Abnormal vaginal discharge: causes include candidiasis, bacterial vaginosis, chlamydia and gonorrhoea.
  • Scarring: may relate to previous surgery (e.g. episiotomy) or lichen sclerosus (destructive scarring with associated adhesions).
  • Vaginal atrophy: most commonly occurs in postmenopausal women.
  • White lesions: may be patchy or in a figure of eight distribution around the vulva and anus, associated with lichen sclerosus.
  • Masses: causes include Bartholin’s cyst and vulval malignancy.
  • Varicosities: varicose veins secondary to chronic venous disease or obstruction in the pelvis (e.g. pelvic malignancy).

2. Inspect for evidence of vaginal prolapse (a bulge visible protruding from the vagina). Asking the patient to cough as you inspect can exacerbate the lump and help confirm the presence of prolapse.

  • Inspect Vulva
    Inspect the vulva
Bartholin’s cyst

Bartholin’s glands are responsible for producing secretions which maintain vaginal moisture and are typically located at 4 and 8 o’clock in relation to the vaginal introitus. These glands can become blocked and/or infected, resulting in cyst formation. Typical findings on clinical examination include a unilateral, fluctuant mass, which may or may not be tender.

Lichen sclerosus

Lichen sclerosus is a chronic inflammatory dermatological condition that can affect the anogenital region in women. It presents with pruritis and clinical examination typically reveals white thickened patches. Destructive scarring and adhesions develop causing distortion of the normal vaginal architecture (shrinking of the labia, narrowing of the introitus, obscuration of the clitoris).

Abnormal vaginal discharge

There are several causes of abnormal vaginal discharge including:

  • Bacterial vaginosis: a thin, profuse fishy-smelling discharge without pruritis or inflammation.
  • Candidiasis: a curd-like, non-offensive discharge with associated pruritis and inflammation.
  • Chlamydia and gonorrhoea (symptomatic): a purulent vaginal discharge with or without associated inflammation.
  • Trichomoniasis: an offensive yellow, frothy vaginal discharge with associated pruritis and inflammation.

Inserting the speculum

Warn the patient you are going to insert the speculum and ask if they’re still ok for you to do so.

If the patient consents to the continuation of the procedure:

1. Use your left hand (index finger and thumb) to separate the labia.

2. Gently insert the speculum sideways (blades closed, angled downwards).

3. Once inserted, rotate the speculum back 90° so that the handle is facing upwards.

4. Open the speculum blades until an optimal view of the cervix is achieved.

5. Tighten the locking nut to fix the position of the blades.

  • Insert Speculum
    Gently insert the speculum sideways with the blades closed

Visualising the cervix

Inspect the cervix:

  • Identify the cervical os: if open, this may indicate an inevitable or incomplete miscarriage.
  • Inspect for erosions around the os: most commonly associated with ectropion however early cervical cancer can have similar appearances.
  • Cervical masses: typically associated with cervical malignancy.
  • Ulceration: most commonly associated with genital herpes.
  • Abnormal discharge: several possible causes including bacterial vaginosis, vaginal candidiasis, trichomonas, chlamydia and gonorrhoea.
  • Inspect cervix
    Inspect the cervix
Cervical ectropion

Cervical ectropion is a condition in which the columnar epithelial cells which are normally located inside the cervical canal are present on the outside of the vaginal cervix (normally the only cells on the outside of the vaginal cervix are squamous epithelial cells). The areas of columnar epithelial cells appear red against the normal pink colour of the cervix and are often located around the external os. They are more prone to bleeding, due to the presence of a network of delicate fine blood vessels, and as a result, patients often present with post-coital bleeding.

Cervical cancer

Cervical cancer is caused by persistent infection with human papillomavirus (HPV). Prior to the development of cervical cancer, the cells of the cervix can become dysplastic, a condition that is known as cervical intraepithelial neoplasia (CIN). Cervical screening can identify patients infected with HPV who have CIN, allowing early treatment to prevent progression to invasive cervical cancer. Many women do not have symptoms in the early stages of cervical cancer, but symptoms can include vaginal bleeding (intermenstrual, post-coital), increased vaginal discharge and vaginal discomfort. Clinical examination typically reveals white or red patches on the cervix in early disease or the presence of a cervical ulcer or tumour in more advanced disease.


Cervical screening sample

1. Insert the endocervical brush through speculum into the endocervical canal, avoiding touching the sides of the speculum with the brush.

2. Rotate the brush 5 times, 360 degrees, in a clockwise direction.

3. Remove the endocervical brush, avoiding touching the speculum as you do so.

4. Deposit the tip of the endocervical brush into a liquid-based cytology container.

  • Insert the endocervical brush
    Gently insert the endocervical brush into the external os

Removing the speculum

1. Loosen the locking nut on the speculum and partially close the blades.

2. Rotate the speculum 90°, back to its original insertion orientation.

3. Gently remove the speculum, inspecting the walls of the vagina as you do so.

4. Cover the patient with the sheet, explain that the examination is now complete and provide the patient with privacy so they can get dressed. Provide paper towels for the patient to clean themselves.

5. Dispose of the used equipment into a clinical waste bin.

6. Wash your hands.

  • Loosen the locking nut
    Loosen the locking nut

To complete the procedure…

Thank the patient for their time.

Label the sample.

Document the procedure in the medical notes including the details of the chaperone.

Summarise your findings.

Example summary

“Today I examined Mrs Smith, a 28-year-old female. On general inspection, the patient appeared comfortable at rest. There were no objects or medical equipment around the bed of relevance.

“There were no abnormalities noted on inspection of the vulva and speculum examination revealed a healthy cervix with a closed external os. I was able to obtain an adequate sample for cervical screening.”

“In summary, these findings are consistent with a normal speculum examination.”

“For completeness, I would like to perform the following further assessments and investigations.”

Further assessments and investigations

  • Urinalysis: including β-HCG to rule out pregnancy (e.g. ectopic pregnancy).
  • Vaginal swabs/endocervical swabs: if there are concerns about infection (bacterial/viral).
  • Bimanual vaginal examination: to assess the uterus and adnexa for masses.
  • Complete abdominal examination: if there are concerns about intraabdominal pathology (e.g. appendicitis).
  • Ultrasound abdomen and pelvis: to further investigate pelvic pathology.
  • HPV testing: can be performed on the same cervical screening sample if using liquid-based cytology (no extra swabs required).

Reviewer

Mr Isaac Magani

Consultant Obstetrician 


References

  1. Medimage. Adapted by Geeky Medics. Bartholin’s cyst. Licence: CC BY-SA. Available from: [LINK].

  2. Mikael Häggström. Adapted by Geeky Medics. Lichen sclerosus. Licence: CC0. Available from: [LINK].

  3. Mikael Häggström. Adapted by Geeky Medics. Vaginal candidiasis. Licence: CC0. Available from: [LINK].

  4. Mikael Häggström. Adapted by Geeky Medics. Uterine prolapse. Licence: CC0. Available from: [LINK].

  5. GynaeImages. Adapted by Geeky Medics. Cervical ectropion. Licence: CC BY-SA. Available from: [LINK].

  6. Haeok Lee, Mary Sue Makin, Jasintha T Mtengezo and Address Malata. Adapted by Geeky Medics. CIN-1. Licence: CC BY. Available from: [LINK].


 

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