UN DESTIN COMMUN POUR UN AVENIR MEILLEUR

Christine M Bates
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.
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

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.
1 Wilson JD, Robinson AJ, Kinghorn SA, Hicks DA,
Implications of inflammatory changes on cervical cytology.
BMJ 1990;300:638-40.
2 Came CA, Dockerty G. Genital warts; need to screen for
coinfection. BMJ 1990;300:459.
3 Wemess BA. Cytopathology of sexually transmitted disease.
Clin Lab Med 1989;9:559-72.
4 Sekhri A, Le Faou AE, Tardieu JC, Antz M, Fabre M.
What can be expected from the cytologic examination of
cervicovaginal smears for the diagnosis of Chlamydia trachomatis
infection? Acta Cytol 1988;32:805-10.
5 Ghirardini C, Boselli F, Messi P, Rivasi F, Trentini GP.
Chlamydia trachomatis infection in asymptomatic
women. Results of a study employing different staining
techniques. Acta Cytol 1989;33:115-9.
6 Arroyo G, Linnemann C, Wesseler T. Role of
Papanincolaou smear in diagnosis of chlamydial infections.
Sex Transm Dis 1989;16:11-4.
7 Sharp F, Duncan ID, Evans DMD, et al. Report of the
Intercollegiate Working Party on Cervical Cytology
Screening. Royal College of Obstetrics & Gynaecology
1987: London.
8 Kelly BA, Black AS. The inflammatory cervical smear: a
study in general practice. Br J Gen Pract 1990;40:
238-40.
9 Avonts D, Sercu M, Heyerick P, Vandermeeren I, Piot P.
Sexually transmitted diseases and Chlamydia trachomatis
in women consulting for contraception. Journal Royal
CoUege General Practitioners 1989;39:418-20.
10 Macaulay ME, Riordan T, James JM, et al. A prospective