UN DESTIN COMMUN POUR UN AVENIR MEILLEUR

Abstract
Object-To ascertain the management of
inflammatory smear results by general
practitioners.
Design-Postal questionnaire survey.
Subjects-All 200 general practitioners
on Wirral Family Health Services
Authority list as principals in 1990 and
1991.
Main outcome measures-Answers to
questions covering a variety of aspects
concerning the management of inflammatory
smear results in general practice.
Results-One hundred and thirteen
(57%/O) replied. Ninety per cent have
facilities to test for Trchomonas vaginalis
and Candida albicans. Sixty eight
per cent were able to test for Chlamydia
trachomatis. A high vaginal swab (HVS)
was the commonest swab taken (88%);
31% of doctors included a swab for
Chlamydia trachomatis. Of doctors who
gave treatment without microbiological
confirmation 74% gave metronidazole
and 64% gave tetracycline or erythromycin.
Eighty five per cent repeat
smears are undertaken within three
months. Ninety seven per cent of doctors
said more detailed information would be
helpful on the cytology report. One hundred
per cent of doctors referred to a
gynaecologist if colposcopy was advised.
Male sexual partners were advised to
attend the Department of Genitourinary
Medicine by 12% of doctors (70% do not
refer to either their general practitioner
or genitourinary department).
Conclusion-Most patients with inflammatory
smear results are managed by
their general practitioner without reference
to specialist services. Many patients
are not investigated for infection but
treatment often includes medication
which covers the most likely or
potentially serious genital pathogens.
More detailed advice given with the
cytology report on further management
or a local protocol would be helpful to aid
management in this difficult area. If
recommendations for referral of certain
groups of patients to genitourinary
departients were implemented the present
workload of the department would
be increased.
(Genitourin Med 1993;69:126-129)
Introduction
Inflammatory changes on cervical cytology
are not infrequently associated with sexually
transmitted infection' and it is well recognised
that more than one sexually transmitted disease
may coexist making screening for other
infections advisable.2
Cytopathological appearances on the
Papanicolau smear may suggest specific
pathogens: Trichomonas vaginalis, candida
species, Gardnerella vaginalis, human papilloma
virus, Chlamydia trachomatis and herpes
simplex virus, but the sensitivity and specificity
in respect of Chlamydia trachomatis is disputed.'
3
As a result of the British Society for
Clinical Cytology working party recommendation7
abnormal smear results are
accompanied by advice on management; for
example, "investigate, treat and repeat" is
now added to a report where inflammatory
changes are seen on cervical cytology.
A recent study in the community8 found
5% of smears taken in one year in one general
practice were reported as inflammatory,
almost half of which had microbiologically
proven infection when subsequently investigated,
the commonest infecting organisms
being gardnerella and candida, which agrees
with the findings of an earlier study in general
practice.9
In another community based study where
patients with inflammatory smears were
referred to a department of genitourinary
medicine for investigation, genital infection
was found in three quarters, a fifth of whom
had coexistent infection.' The prevalence of
Chlamydia trachomatis in this study was 18%
(previous studies have shown prevalences of
5.7%-7.3%).9-12
In view of this the authors suggested that,
notwithstanding the constraints of the service,
certain categories of patients should be
referred to departments of genitourinary
medicine for further investigation whilst the
remaining patients (such as those under 25
years of age or with recent change in sexual
partner) should have a repeat smear, and be
referred should the result again be unsatisfactory.
This is much the same as the suggested
management by Singer.'3
A survey was undertaken of general practitioners
in the Wirral Area to ascertain the
usual management of patients with inflammatory
smears and to see how this compared
with recent recommendations.' 1" If there is a
126
Department of
Genito-Urinary
Medicine, Arrowe
Park Hospital,
Wirral, Merseyside,
L49 SPE
C M Bates
Accepted for publication
21 October 1992
The management ofpatients with inflammatory smear results in general practice
great divergence of practice this has implications
for possible changes in the workload of
various departments, including hospital
departments of genitourinary medicine
(GUM), gynaecology, cytology and microbiology
as well as general practitioners themselves,
should these recommendations be
implemented. It also has implications for the
patients and their sexual partners who may
not be adequately investigated, treated and
followed up, which, especially in terms of
Chlamydia trachomatis, may have long-term
sequelae.
Method
General practitioners (n = 200) on the Wirral
Family Health Authority list were sent a
postal questionnaire during the period
December 1990 to March 1991. The questionnaire
asked doctors to state what facilities
they had for routinely taking swabs for
vaginal and cervical infections and in what
circumstances they would include swabs for
infection when taking a routine cervical
smear.
Doctors were asked how patients were
made aware of abnormal smear results and
what arrangements are made for further
follow-up. Also, how important they thought
screening for sexually transmitted diseases
was in patients with inflammatory smears and
what investigations, if any, were undertaken if
such a report was received. They were asked
if they screened for additional genital
infections if a specific infection such as
Trichomonas vaginalis or candida was reported
by the cytology laboratory.
Doctors were asked to indicate what treatment,
if any, was given and how long they
would wait before a repeat smear was performed.
Views on advice given in smear
reports were obtained, as was the likely
choice for referral if colposcopy was advised.
Doctors were asked whether they recommended
that the male sexual partners of
patients with inflammatory smears consult
either their own general practitioner or the
genitourinary medicine department. Finally,
comments regarding the management of an
abnormal smear result were invited.
Results
A total of 113 (57%) replies were received,
one of which was excluded as the doctor stated
that he did not deal with smears in his
practice. Of the remaining 112, table 1 shows
their facilities, including swabs, transport
media and access to laboratory for routine
testing for genital infection. Almost all doctors
are able to investigate for common vaginal
pathogens such as Trichomonas vaginalis
and candida, and 68% can test for Chlamydia
trachomatis. A third are able to take specimens
for Neisseria gonorrhoeae whilst 15% can
test for herpes simplex virus. Six reported
that they had no facilities at all.
When taking an initial routine cervical
smear three doctors also undertook investiga-
Table1 Genital infections for which
facilities to investigate
112 doctors had
Genital infection No (%) of doctors
Neisseria gonorrhoeae 37 (33)
Mycoplasma sp Ureaplasma urealyticum 12 (1 1)
Chlamydia trachomatis 76 (68)
Herpes simplex virus 17 (15)
Trichomonas vaginalis
Candida albicans 101 (90)
Gardnerella vaginalis J
All of these 7 (6)
None of these 6 (5)
tion to exclude genital infection; 97 (87%)
said they would do so if the patient had
symptoms whilst 57 (51%) would take swabs
if the patient's sexual partner had a sexually
transmitted infection and 64 (59%) would if
the previous smear showed an infection.
Patients were made aware of abnormal
results either by being asked to contact the
surgery themselves [39 (35%)] or by direct
contact by telephone or letter by the doctor
or practice nurse [69 (62%)]. In both cases
the patient is usually asked to make an
appointment to discuss the result with the
doctor. One doctor relied solely on the
Family Health Services Authority (FHSA) to
contact the patient; nine others cited this as
an additional method. Where the patient had
been asked to make contact most doctors
added that if they had not done so within a
month or if referral had been recommended
the practice would then contact the patient
instead.
Follow-up was ensured by 33 (30%) doctors
using their own computer recall system,
44 (40%) using a manual recall system of
either a diary, tagging notes or keeping a separate
list of abnormal results; five (5%) relied
on the FHSA computer recall; 16 (15%)
relied on the patient to ensure their own follow
up having explained the need for this.
Eleven (10%) of doctors did not specify how
they followed patients up.
Attitudes to the importance of screening
for sexually transmitted diseases (STDs) in
patients with inflammatory smears covered a
range of views: 16 (14%) doctors thought it
obligatory, 54% desirable but not essential;
30% unlikely to be cost effective; 9 did not
express a view.
Table 2 shows what investigations are
undertaken if a report of "inflammatory cells,
investigate, treat and repeat" is received.
The swab most commonly taken is that of
high vaginal swab (HVS): 99 (88%) of
respondents cite this as one they would take.
Forty eight of the 112 said an HVS would be
Table 2 Investigations undertaken by doctors when a
report of inflammatory cells, investigate, treat and repeat is
received
Investigation undemaken No (%) of doctors
High vaginal swab (HVS) only 48 (43)
HVS
Urethral swabs for N gonorrhoeae 2 2
Cervical swabs Chlamydia trachomatis (2)
herpes simplex virus
Cervical swab for Chlamydia trachomatis 35 (31)
HVS and cervical swab for Ngonorrhoeae 13 (12)
Swabs including HVS 99 (88)
No investigation undertaken 6 (5)
127
Bates
the only swab they would take. Two replied
that urethral and cervical swabs for Neisseria
gonorrhoeae, Chlamydia trachomatis, an HVS
and a cervical swab for herpes simplex virus
would all be taken. Thirty one per cent of
doctors included a swab for Chlamydia trachomatis
usually in addition to an HVS. Six
stated that they would take no swabs.
Asked if they screened routinely for other
STDs if a specific infection (such as
Trichomonas vaginalis or Candida albicans)
was reported as being seen on a cervical
smear, eight (7%) said they would; 100
(89%) would not, although six of these said
they sent patients to the genitourinary medicine
department for further investigation.
Sixty six (59%) said they would screen for
other STDs only if the patients had symptoms;
36 (32%) would not look for coincidental
infections at all.
When a patient was reported to have an
inflammatory smear 27 (24%) doctors treated
blind without waiting for microbiological
confirmation of infection; 53 (47%) waited
for results of swabs whilst 31 (28%) practise a
combination of methods depending on clinical
circumstances.
Of those treating blind at any point a wide
variation of preparations are prescribed;
metronidazole was the commonest choice; 43
out of 58 doctors (74%) said they used this
usually in combination with an antifungal
agent.
Thirty seven (64%) replied that they gave
either tetracycline or erythromycin (both
effective against chlamydial infection) again
usually in combination with either metronidazole
and/or an antifungal agent.
Six gave antifungal agents alone, four gave
metronidazole alone and one doctor used sultrin
only. Three used cephalosporins in combination
with metronidazole and one gave
betadine pessaries with metronidazole. Table
3 lists the medication used to treat patients
with inflammatory smear results without
microbiological evidence of infection.
Table 4 shows the time allowed to elapse
Table 3 Medication prescribed before microbial
confirmation. Figures are numbers (percentage) of 58
doctors who "treat blind".
Medication No (%) doctors
Tetracycline 13 (22)
Erythromycin 24 (41)
Antifungal 33 (57)
Metronidazole 43 (74)
Cephalosporin 3 (5)
Penicillin or derivative 2 (3)
Vaginal Antibacterial Cream 2 (3)
(Sultrin Betadine)
Table 4 Time allowed to elapse before repeat smear is
performed. Figures are number (percentage) of 109 doctors
who responded
Time in months No (%lo) of doctors
< 3 66 (61)
93 (85)
3 27 (25) J
3-6 5 (5)
6 10 (9)
12 1 (1)
before repeat smears are performed. This
ranges from three weeks to one year, the
majority being performed within three
months. Twenty four doctors said that they
followed the laboratory recommendation
(normally repeating the smear 2-6 weeks after
treatment) and two of these relied on computer
recall by the FHSA.
Of 109 doctors who replied, 79 (72%) felt
that the advice on further management given
on the smear report was clinically relevant
and helpful; 29 (27%) were not satisfied. One
hundred and six (97%) answered that more
detailed advice, for example, a suggestion of
the likely pathogen, would be desirable.
Doctors were asked where they referred
patients when colposcopy was advised on the
smear report; three general practitioners
failed to answer this part of the questionnaire.
Of the remaining 109 doctors 109 (100%)
referred the patient to a gynaecologist.
Additionally, three occasionally referred the
patient to a GUM department and one specified
colposcopy clinic.
Concerning male sexual partners of
patients with inflammatory smears, 76 (70%)
doctors said they would not ask them to visit
either their family doctor or the GUM
department. Thirty one (28%) doctors would
ask them to attend their own family doctor
(of these 13 would alternatively ask them to
attend the GUM department). In total 94
(86%) would not ask them to attend the
GUM department. Again, three doctors
failed to answer this question.
Finally, general comments on the subject
of inflammatory smear results were invited
and these are considered in the discussion.
Discussion
The majority of doctors replying to the questionnaire
have facilities for testing for the
commoner genital pathogens such as Candida
albicans, Trichomonas vaginalis, Gardnerella
vaginalis and Chlamydia trachomatis (two doctors
reported difficulty in obtaining
Chlamydia transport medium in sufficient
quantity to allow routine testing for chlamydia).
Despite seemingly adequate facilities
only 14% of doctors felt that screening for
STDs in patients with inflammatory smears is
essential. When investigation is undertaken
an HVS is cited as the only swab taken by
almost half the doctors. According to studies
in the community the commonest microbiologically
proven infections are gardnerella and
candida.89 The prevalence of Chlamydia trachomatis
has been reported as ranging from
5.7 - 18%.' 9-12 More than two thirds of
respondents did not include swabs for
Chlamydia trachomatis in these investigations
despite the fact that 68% reported that they
had facilities to do so. This could mean that a
small but significant number of infections are
missed. However, this seems unlikely as the
majority (64%) of doctors treating a patient
with an inflammatory smear (without microbiological
confirmation) include medication
which is effective against chlamydia.
128
The management ofpatients with inflammatory smear results in general practice
It is a well recognised fact in GUM departments
that more than one STD may coexist
and that screening for other infections is
desirable. Eighty nine per cent of doctors
replied that they would not routinely do this,
although six of these would send the patient
to the GUM department. Even if the patient
was symptomatic 36 doctors said that they
would not look for coexistent infections.
When colposcopy is advised by the cytology
laboratory, without exception all respondents
refer the patient to a gynaecologist for
further management. (Only three doctors said
they occasionally referred to the GUM
Department.) Referral pattems will reflect the
local arrangements between gynaecology and
GUM department and availability of the service
provided although also it may indicate
that it is less acceptable to general practitioners
and their patients to attend the GUM
department than a gynaecology clinic or a
colposcopy clinic run by gynaecologists. One
doctor queried how acceptable cervical cytology
as a screening test would remain if
patients with inflammatory smears (an
increasing proportion of smears taken in the
practice in his experience) were to be investigated
for STDs.
Only a minority of doctors said they would
advise the male sexual partners of patients
with inflammatory smears to be checked; of
these most preferred to send them to their
own general practitioner rather than the
GUM department. Factors may include the
perceived stigma of attending a GUM clinic
or the implication of doing so, for example,
where questions on life insurance forms may
relate to past attendance or treatment of STD
at a GUM clinic.
Many doctors used the questionnaire as an
opportunity to air their concern regarding the
management of inflammatory smears. The
apparent commonality of the inflammatory
smear report and the impression that it often
may return to normal on repeat testing was
mentioned by several doctors. Ten doctors
asked if a protocol for management could be
drawn up or if more specific help in the likely
cause of infection could be given. It is apparent
that few patients, or their partners, are
referred to GUM departments following an
inflammatory smear report for investigation.
It would, therefore, seem prudent that, if
patients are to be managed by their general
practitioner that guidelines be issued, either
as a local protocol or possibly in the form of a
notice attached to the smear report, with
regard to further investigation and treatment
with and indication as to when referral to a
GUM Department might be appropriate.
I thank Dr IA Tait and Dr AK Ghosh for their advice and
encouragement and Mrs Mary Percy and Mrs Amanda Jelley
for their invaluable secretarial support.
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