Although illegal in the United Kingdom, female circumcision (also known as female genital mutilation) is still practised within some cultures. This involves deliberate physical damage to the architecture of the vulva of the adolescent or young woman. It is usually carried out by older women within the same culture. The procedure may be carried out with or without anaesthesia; however, with anaesthesia the extent of the circumcision can be even more radical. Ill consequences to health include menstrual problems, recurrent urinary tract infections, pain and difficulties having sex, reduced sexual pleasure (from partial or complete removal of the clitoris) and obstructed labour (http://www.who.int/mediacentre/factsheets/fs241/en/index.html). Sensitivity in dealing with this complex issue is vital. Other young women in the same family or social network may be at future risk, and there may be an opportunity for intervention to prevent this.
A metal speculum should be warmed to body temperature prior to use; however, a plastic speculum can be used at room temperature. A small amount of water-based lubricant may be required to facilitate ease of examination and increased comfort for the woman. The patient should be advised as to expected sensations (for example, a stretching sensation on opening the blades). Nonverbal and verbal cues should be monitored carefully during the examination, and the pace of the examination should be adapted to the individual. Pausing at the introitus before passing the speculum allows for the patient to register the fact that the examination is about to begin at a physiological level. A gentle but confident approach should be taken. The speculum is passed slowly and smoothly, taking care not to trap the pubic hair or labia. Unless the uterus is known to be retroverted, the speculum is introduced according to the physiological tilt of the vagina (upwards at an approximately 45-degree angle). Once fully inserted, the blades are opened slightly, and if necessary minor adjustments are made until the cervix is in view. Once the cervix is visible, the blades can be opened further to bring the cervix fully into view. Care should be taken to avoid pressing against the urethra during the process of adjustment. If the uterus is retroverted, it may be necessary to remove and reposition the speculum accordingly.
Once the speculum is in place, careful observation should be made of the vagina and cervix. A sample may be taken from the lateral vaginal walls for Candida and bacterial vaginosis using either a cotton-tipped or a loop swab. To ensure a good sample, a scraping action to the actual walls of the vagina is used (as opposed to just collecting vaginal discharge). The sample is then applied thinly to a plain slide, in preparation for Gram stain and microscopy. The same sample may also be used to culture for Candida, for example, using the Saboraud medium. A gentle sweeping action should be used to ensure that the agar remains intact. Using the same type of swab a sample is taken from the posterior fornix (at the top of the vagina, underneath the cervix) for Trichomonas vaginalis. A sweeping motion from side to side is used. Once the sample has been obtained the swab is gently agitated into a few drops of normal (0.9%) saline on a plain slide and a cover slip is then applied.This 'wet prep' or 'wet mount' sample can be read in either a dark or light microscope for trichomonads.
In preparation for gonorrhoea and Chlamydia samples, a larger cotton-tipped swab or 'mop' is gently used to sweep away excess mucus from the cervix. Usually one mop is sufficient, but it is useful to have an extra one ready to hand for heavier cervical discharge/blood. The gonorrhoea sample is collected first, using the same type of swab as for vaginal samples. The tip of the swab is gently inserted into the cervical os. All aspects of the cervical opening should be fully sampled using a rotational movement and the swab removed. The sample can be applied thinly to a plain slide for Gram stain and microscopy and inoculated into a selective medium for culture and sensitivity tests on Neisseria gonorrhoeae. Again, a gentle sweeping action is used to ensure the agar remains intact. A cotton-tipped cervical swab is supplied with the appropriate Chlamydia testing kit. The tip of the swab is gently inserted into the cervical os and then agitated in a circular motion for at least 10 seconds or as per the manufacturer's instructions. To ensure a good specimen is collected all aspects of the cervical opening should be sampled and firm pressure used to pick up cervical cells. The sample is then placed into the Chlamydia transport medium.
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