Nabothian follicles

Nabothian follicles may appear as small white papules on the cervix. These are not harmful and may eventually disappear.

CERVICAL CYTOLOGY

Routine cervical cytology is ideally carried out within general practice or community contraception clinics where follow-up of patients may be less problematic than within the GUM setting. However, there is a role for GUM practitioners in promoting understanding and allaying fears about the cervical screening programme, and in encouraging women to attend for smears. The history of cervical screening should be discussed and documented. Where the woman has missed attending for smears and is unlikely to attend other services, an opportunistic smear carried out with the woman's consent may be a pragmatic solution, and should be taken prior to cervical swabs to ensure an adequate sample. A smear should also be considered with clinical signs and symptoms, including unexplained bleeding and clinically abnormal changes to the cervix. An urgent referral should be made to colposcopy for further assessment.

REMOVING THE SPECULUM

Removing the speculum after the examination should be approached with as much care as insertion so as to avoid unnecessary discomfort. The speculum should be moved away from the cervix before beginning to close the blades. The blades are then closed smoothly and slowly and the speculum withdrawn, taking care to avoid trapping the vaginal walls, the labia or the pubic hair in the blades.

BIMANUAL EXAMINATION

During bimanual examination the practitioner gently inserts one or two gloved fingers into the vagina using water-based lubricant. The other hand is used to palpate across the abdomen. A gentle but firm approach is taken to feel the reproductive organs, checking for signs of tenderness/pain and any masses. Verbal and non-verbal communication should be closely monitored throughout the examination. A mass is highly likely to be a fibroid, although it could be a malignant tumour, and should be referred for further investigation. Within a GUM setting significant adnexal tenderness would be presumptively treated as Pelvic Inflammatory Disease (PID). If the fallopian tubes are palpable or pulsating ectopic pregnancy should be considered. In this event urgent referral to gynaecology is indicated (Jarvis, 2000).

After the examination tissues should be offered to remove the lubricant if any was used. It is important to pre-empt possible concerns; for example, the patient may experience light bleeding following cervical tests, which is normal. Sanitary protection should be offered if bleeding was noted on examination.

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