Vaginal vault screening

• After total hysterectomy (operation to remove uterus including cervix) — woman may need vaginal vault screening to detect changes that can lead to vaginal cancer
• After subtotal hysterectomy (operation to remove body of uterus but not cervix) — woman needs regular cervical screening every 5 years. Risk of cervical cancer is the same as women who haven't had a hysterectomy

Deciding who should have vaginal vault screening

Check

• Type of hysterectomy 
• Total — may need vault smear see Flowchart 6.1
• Subtotal — cervical screening

Do

• Follow Flowchart 6.1
• First row — cervical screening history
• Second row — indication for hysterectomy
• Third row — cervical histopathology result
• Fourth row — required follow-up 

Women do not need vaginal vault screening if

• Total hysterectomy for benign gynaecological disease with no cervical pathology
• AND normal cervical screening history
• OR treated HSIL with completed 'Test of Cure'

Medical/gynaecology consult about need for vaginal vault screening IF

• Hysterectomy for non-benign condition, including HSIL (CIN 2/3), adenocarcinoma-in-situ (AIS), cervical or other genital tract cancer. Ideally, talk with gynaecologist who did hysterectomy to work out best plan for each woman
• Reason for hysterectomy not known
• Cervical screening history not known
• History of abnormal cervical screening (or Pap smear) or treatment for HSIL/AIS and/or 'Test of Cure' not completed
• History of genital tract cancer, even if not main reason for hysterectomy

Doing vaginal vault screening

What you need

• Liquid based cytology (LBC) vial (eg Thinprep, SurePath) labelled with woman's name, date of birth
• Choice of sampling tool/s
• Cervix sampler 'broom' — preferred tool
• Plastic spatula — do not use wooden spatula

What you do

• Do speculum examination 
• Find hysterectomy suture line on anterior vaginal wall — use cervix sampler or blunt end of plastic spatula to take sample from suture line
• If suture line not seen — take sample from end of vagina
• Continue as for cervical screening — see After taking sample
• Take swabs for STI tests
• If vaginal discharge — see Vaginal discharge
• 2 tests possible depending on recommended follow-up in Flowchart 6.1
• Usually 'Test of Cure' — request 'HPV+LBC co-test'
• Occasionally HPV test only — request 'HPV test'
• See Table 6.2 for more information on tests

Follow-up

• Talk to woman about coming back for results
• Medical consult about any abnormal findings
• If positive test result (HPV or LBC) — refer for colposcopy