Vulva, Vagina, and Anus
containing cellular, well preserved, and adequately fixed mate-
rial may be more important for determining adequacy than the
presence of a t-zone component.106 In addition, the presence of
fecal material, inflammation, excessive bacteria, poor preserva-
tion, and excessive air-drying artifact may contribute to poor
visualization of abnormal cells in anorectal samples. These
factors tend to be more prevalent in conventional smears and
the use of thin-layer, liquid-based preparations can reduce the
presence of these factors, thereby contributing to fewer false-
Anal Cytologic Screening Guidelines
Currently there is no official guideline regarding anal cytol-
ogy as screening for anal SIL. The following is based on the
approach used by the group at the University of California at
San Francisco, which is spearheading the clinical research on
HIV-negative men with history o f receptive anal intercourse
or anal warts.
If the first anal Pap is negative, it should
be repeated in 6 months. If the second Pap is nega-
tive, then repeat Pap should be obtained in 3 to 5
HIV-positive men with history o f anal intercourse or anal
If the first anal Pap is negative, it should be
repeated in 6 months. If the second Pap is negative,
then repeat cytology should be obtained in one year.
It has been suggested that patients with CD4 counts
< 500 mm should be screened more frequently.
HIV-negative women with history o f anal warts, cervico-
vaginal HSIL, VIN, or invasive cervical cancer.
If the first
anal Pap is negative, it should be repeated in
6 months. If the second Pap is negative, then repeat
Pap should be obtained in 3 to 5 years.
If the first anal Pap is negative, it
should be repeated in 6 months. If the second Pap is
negative, then repeat cytology should be obtained in
one year. Some clinicians screen patients with CD4
counts < 500 mm more frequently.
5. Consider screening patients with organ transplants on
chronic immunosuppressive agents.
Vulvar and vaginal exfoliative cytology, when appropriately
employed, may provide valuable information about the nature
of a lesion. Exfoliative cytology of these sites; however, is not a
substitute for biopsy. A wide variety of infectious and inflam-
matory diseases, dermatologic diseases, and benign and malig-
nant tumors have characteristic cytologic features that have been
described above. Unsuspected cancer is rarely identified by this
approach. Many of the cytologic features at these sites are similar
to those of cervical PAP cytology. Fine-needle aspiration (FNA)
cytology can also be particularly useful in assessing palpable
subcutaneous or submucosal lesions of the vulva and vagina.
Although anal PAP cytology share many essential features
with cervical PAP cytology, recognizing salient diagnostic fea-
tures and pitfalls in anal PAP will facilitate the accurate detec-
tion of anal squamous dysplasia. Atypical keratinized squamous
cells are commonly seen in anal PAP. Therefore, nonkeratinized
squamous cells with higher N/C ratio, rather than atypical para-
keratosis alone, are required for diagnosis of anal HSIL. On
the other hand, as high-grade AIN was found in up to 50% of
patients with cytologic diagnosis of ASC or LSIL, reflex HPV
DNA testing might be helpful in triaging patients diagnosed
with ASC and patients diagnosed with LSIL or above should go
directly to anoscopic biopsy.
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