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Unsatisfactory Pap Collections

Most likely, the most problematic pap interpretation is that of an Unsatisfactory interpretation.  Unfortunately, even the most experienced practitioner eventually experiences an unsatisfactory result.  It is important to understand the criteria used when determining adequacy and address some common concerns.  We offer tips in this article to assist practitioners in lowering unsatisfactory pap rates. 
Satisfactory vs. Unsatisfactory:  The first check at MACL is to determine if our technical processes are at fault. We will rerun the test if necessary.  Our guidance for determining adequacy comes from The Bethesda System for Reporting Cervical Cytology 2001.  These guidelines state that a minimum of 5000 well-visualized/preserved squamous cells are needed for a specimen to be considered satisfactory.  At MACL, we apply these standards to most adequacy assessments.  However, we also recognize that strict objective criteria cannot be applied in every case.  For example, if the collection is from a total hysterectomy or an atrophic patient with negative histories, we will relax our adequacy criteria.  It is our requirement that every unsatisfactory case undergoes professional hierarchical review before an unsatisfactory is released.  Every unsatisfactory is recorded for future reference.
How can blood interference be avoided? Blood dilutes the ThinPrep liquid and interferes with epithelial cells getting to the slide used for microscopic evaluation.  Patients in menses should be rescheduled for their pap collection.  On the other hand, there is little that can be done when the cervix is friable and bleeding occurs.  All bloody specimens are reprocessed with a technique that lyses the red blood cells.  Reprocessing delays patient results but there is some success in obtaining satisfactory specimens.
How can mucus and inflammation be avoided? Mucus and inflammation are combined because they are often co-contributors. When we report inflammation, we are usually seeing a marked presence of acute inflammatory cells. These are usually trapped in mucus. Wiping the surface of the cervix with a swab can be used to remove excess mucus.
What can I do about issues related to lubricants? Warm water on the speculum is recommended rather than lubricant. If you do use lubricant, use it sparingly to avoid smearing on the area being sampled and use one of these four recommended brands: Surgilube, Astroglide, Crystelle, or Aseptic Control Lubricant.
How should I advise patients about personal lubricant use? According to one study, you should advise patients to avoid use of lubricants and some vaginal medications for 72+ hours prior to their scheduled pap test ( 10.3122/jabfm.2011.02.100086 J Am Board Fam Med March-April 2011 vol. 24 no. 2 181-186).  For example, hypersomatic lubricants such as KY Warming Liquid can irritate the epithelium and promote increased mucus production which, in turn, can interfere with the pap test.  Bioadhesive polymers such as carbomers and carbopol polymers (eg, Replens lubricant and Monistat creams) may also interfere.  Replens is a commonly used lubricant among postmenopausal women and advertised to last up to three days.  Studies show that as little as 20 uL in the ThinPrep vial can lead to unsatisfactory results.  Monistat 1 contains bioadhesives and only needs to be applied every seven days.
Can you explain how lubricants and certain vaginal medications affect the pap test?  This has everything to do with the way the ThinPrep test is processed.  ThinPrep specimen processing uses a semipermeable membrane filter to transfer cells to a slide.  However, some lubricants and medications present in specimens may clog filters.  The instrument cannot differentiate cells from lubricant and medications.  It responds to the quantity of material it detects on the filter and automatically transfers the filtrate when it reaches a set threshold.  This results in a decreased number of cells being transferred to the slide and inadequate cellularity may result in an ‘Unsatisfactory for Evaluation’ result.
What collection technique yields the optimal specimen? Use a cytobrush and spatula combination. Insert the brush into the cervix until only the bottom fibers are visible. Slowly rotate ¼ to ½ turn in one direction. Do NOT over-rotate as this may cause bleeding. Vigorously twirl the brush and spatula in the liquid at least ten times. Push the brush against the inside wall of the vial to remove any mucus. You can use the spatula to mechanically remove mucus and cells from the cytobrush.
How should I follow up on an unsatisfactory Pap?  ASCCP and ACOG guidelines recommend repeating  the Pap in 2 - 4 months. Treat for infectious organisms identified before repeating the Pap. If a second unsatisfactory is reported, refer the patient for colposcopy1.
Will MACL bill for the unsatisfactory?  We charge for an unsatisfactory pap to recover the cost of the labor and reagents used to determine the unsatisfactory result.
1 Recommendation published by ASCCP.
If you have any questions or concerns, please contact:
Terry Arnold, Cytology Manager

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