Vaginal Swabs – OSCE Guide

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This guide provides a step-by-step approach to performing vaginal swabs in an OSCE setting.


Gather equipment

Collect the relevant equipment, remove the outer packaging and place it in a clean tray:

  • Gloves
  • Lubricant
  • Speculum
  • A light source for the speculum
  • Paper towels
  • Charcoal media swab (high-vaginal or endocervical)
  • Nucleic acid amplification test (NAAT) swabs (vulvovaginal or endocervical)

Introduction

Wash your hands and don PPE if appropriate.

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 take some vaginal swabs. The procedure will involve me inserting a small plastic device called a speculum into the vagina and then taking several swabs from the vagina and 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 or spotting 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 examination?”

Ask the patient if they have any pain or if they think they may be pregnant before proceeding with the clinical 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 hands
    Wash your hands

Vulval inspection

Position

1. Don a pair of non-sterile gloves (if not already wearing some).

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

Explain to the patient you are going to perform a visual examination before taking the swabs. “I’m just going to start by examining the skin.”

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).
  • Female genital mutilation: total or partial removal of the clitoris and/or labia and/or narrowing of the vaginal introitus.
  • Don gloves
    Don gloves

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, lubricate the speculum and carry out the following steps:

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

Inspection of the cervix and vagina

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 a similar appearance.
  • Cervical masses: may be 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.
  • Coil threads: may protrude from the cervical os if the patient has intrauterine contraception fitted. 

Inspect the vaginal walls:

  • Inspect for ulceration and erosions: associated with genital herpes and malignancy.
  • Vaginal atrophy: the vaginal mucosa may appear pale and dry with areas of erythema and bleeding. Vaginal atrophy is often found in post-menopausal women due to oestrogen deficiency.
  • Foreign bodies: including tampons or condoms (these may be found in the posterior fornix).
  • Inspect cervix
    Inspect the cervix

Taking the vaginal swabs

Double vs triple swabs

Depending on your local guidelines you may be expected to take “double swabs” or “triple swabs”:

  • Double swabs: a NAAT swab (endocervical or vulvovaginal) and a high vaginal charcoal media swab.
  • Triple swabs: a NAAT swab (endocervical or vulvovaginal), a high-vaginal charcoal media swab and an endocervical charcoal media swab.

Nucleic acid amplification test (NAAT)

The NAAT swab should be performed first and is used to detect chlamydia and gonorrhoea.

The NAAT kit usually contains two swabs, an endocervical and vulvovaginal. The large tipped white vulvovaginal swab is used to take a sample from the posterior fornix of the vagina and the lower vaginal walls. The thinner endocervical swab is used to take a sample from the cervical os. 

The swab used for a NAAT can either be a vulvovaginal or endocervical swab depending on local guidelines. Only one type of swab needs to be taken for a NAAT. 

Endocervical NAAT swab

To take an endocervical swab:

1. Remove the thin endocervical swab from the packet.

2. With the speculum in situ, pass the tip of the swab through the speculum to the cervical os.

3. Insert the swab gently into the cervical os. If there is excess discharge covering the cervical os, consider using a spare swab to remove this before inserting the endocervical swab. 

4. Rotate the swab for 10-15 seconds in the endocervix.

5. Remove the swab and open the NAAT test tube from the packet. An assistant may be helpful to open the NAAT test tube. It is important not to spill any of the fluid from the test tube.

6. Insert the swab into the NAAT test tube and snap the swab against the side of the test tube along the indicated black line.

7. Screw the lid onto the NAAT test tube.

  • Visualise the cervix
    Visualise the cervix

Vulvovaginal NAAT swab

To take a vulvovaginal swab:

1. Remove the large tipped vulvovaginal swab from the packet.

2. With the speculum in situ, pass the tip of the swab through the speculum to the posterior fornix of the vagina.

3. Rotate the swab for 10 – 15 seconds in the posterior fornix.

4. Remove the swab whilst rotating over the vaginal walls.

5. Open the NAAT test tube from the packet. An assistant may be helpful to open the NAAT test tube. It is important not to spill any of the fluid from the test tube. 

6. Insert the swab into the NAAT test tube and snap the swab against the side of the test tube along the indicated black line. 

7. Screw the lid onto the NAAT test tube.

Charcoal media swab

High-vaginal charcoal media swab

The high-vaginal charcoal media swab is used to detect bacterial vaginosis, trichomonas vaginalis, candida and Group B streptococcus.

To take a high-vaginal charcoal media swab:

1. Remove the testing swab from the tube.

2. With the speculum in situ, pass the tip of the swab through the speculum to the posterior fornix of the vagina.

3. Rotate the swab for 10-15 seconds in the posterior fornix ensuring you swab any discharge present. 

4. Remove the swab and insert it into the tube from which the swab was removed from.

5. Secure the swab into the tube.

  • Visualise the cervix
    Visualise the cervix

Endocervical charcoal media swab 

The endocervical charcoal media swab is used to perform microscopy, culture and sensitivities for gonorrhoea. It is now often performed only when gonorrhoea has been detected on a NAAT prior to the initiation of treatment.

To take an endocervical charcoal media swab:

1. Remove the testing swab from the tube.

2. With the speculum in situ, pass the tip of the swab through the speculum to the cervical os.

3. Insert the swab gently into the cervical os. If there is excess discharge covering the cervical os, consider using a spare swab to remove this before inserting the endocervical swab. 

4. Rotate the swab for 10-15 seconds in the endocervix.

5. Remove the swab and insert it into the tube from which the swab was removed from.

6. Secure the swab into the tube.


Removing the speculum

1. With your non-dominant hand, hold the blades of the speculum whilst you loosen the locking nut with your dominant hand. This ensures the blades do not snap shut when the locking nut is loosened.

2. Gently remove the speculum whilst slowly closing the blades and inspecting the walls of the vagina.

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

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

  • Loosen the locking nut
    Loosen the locking nut

To complete the procedure…

Label the samples with the relevant details.

Thank the patient for their time.

Advise the patient that they’ll be contacted with results via their preferred method (e.g. face to face or text message).

Dispose of PPE appropriately and wash your hands.

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

Send the vaginal swabs to the lab for processing.

Further assessments and investigations


 

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