HPV infection

INFECTION PAPILLOMAVIRUS HUMANO1 (HPV)

Sexually Transmitted Diseases (STDs) are among the most common public health problems worldwide. In industrialized countries there is a new case of DST in 100 people a year, and STDs developing countries are among the top 5 reasons for seeking health services (WHO 1990). 
In recent years, probably due to high transcendence AIDS, working with other STDs, diseases that facilitate HIV transmission, now has added importance, particularly with regard to epidemiological surveillance, training of professionals for the appropriate care, and the availability and control of medicines.

Taking into account the high magnitude estimate of STDs among us, his transcendence, not only for serious consequences for the population, but also for its interaction with HIV, the existence of appropriate technology for their control and the ability to successfully the development of specific activities, the National STD / AIDS is proposed, with the support and participation of states, municipalities, non-governmental organizations and other institutions involved, to regain control of STDs as a priority goal.

CONTROL OF STI IN BRAZIL - INTRODUCTION

In recent years, especially after the worsening AIDS epidemic, STD regained importance as public health problems. However, some problems have been perceived in the context of care for STD in our country:

• there are few epidemiological data on STI; these just AIDS and congenital syphilis are reportable. Rare are the services which the notification is carried out systematically;
• STD patients are still discriminated against in various levels of the health system. The service is often inadequate, resulting in segregation and exposure to embarrassment situations.This happens, for example, when patients have to present their problems in places without privacy or unprepared employees who often demonstrate their own biases when issuing judgments. These situations hurt confidentiality, discriminate against people with STD and contribute them away from health services;
• the irregularity in the supply of specific drugs is perhaps the main cause for the removal of individuals with STD health services. This is by insufficient supply or use for treating other diseases;
• STD for many of the existing laboratory techniques do not exhibit the sensitivity and / or specificity satisfactory. Very few units are able to offer conclusive results of tests at query time. Added to this the fact that the public health system in Brazil has reduced conditions for the tests and often the responsible technicians are unmotivated and / or unprepared.

The most obvious consequence of this situation of low efficiency of the services is the search service in places where it is not necessary to expose or wait in long lines, namely: commercial pharmacies.

AS DST AS A PRIORITY

Why STDs should be prioritized? There are four criteria for prioritizing diseases in public health: magnitude, transcendence, vulnerability and feasibility.

Magnitude:

• although the few existing epidemiological data do not lend themselves to make inferences for the country as a whole, at least allow, when combined with information generated in other countries, the realization of estimates conclude that the high rate of STDs in our country. This, coupled with the high rate of self-medication, makes the problem even bigger, since many cases do not receive the guidance and treatment, getting sub-clinical, remaining transmitters and remaining as the fundamental links in the chain of transmission of diseases.

Transcendence:

• STIs are the main facilitating factor of sexual transmission of HIV;
• some of them, if not diagnosed and treated in time, can progress to serious complications and even death;
• some STDs during pregnancy can be transmitted to the fetus, causing him serious injuries or even causing the spontaneous termination of pregnancy;
• STDs can cause great psychological impact on their carriers;
• STDs also cause great social impact, which translates to indirect costs to the country's economy and that, added to the huge direct costs of hospitalizations and procedures for the treatment of its complications, dramatically elevate these total costs.

Vulnerability:

• STDs, by its epidemiological characteristics, are vulnerable to diseases primary prevention actions, such as the use of condoms, properly, in all sexual relations. In addition, with the exception of STDs caused by viruses, there are effective treatments for all of them; so as you can educate patients of the need to quickly seek a health service to treat yourself properly and their sexual partners if will achieve in the short term, to break the chain of transmission of these diseases and consequently HIV infection .

Feasibility:

• the control of STDs is possible as long as there are good prevention programs and a network of resolute basic services, ie health facilities accessible to emergency department with trained professionals, not only for diagnosis and treatment but also for the proper host and counseling of patients with STD and their sexual partners, and have the guarantee of a continuous flow of drugs and condoms.

PRINCIPLES FOR CONTROL

The basic principles for the control of STDs, like any epidemics control process are as follows:

• interrupt the chain of transmission: objectively acting in "links" that make up this current, ie detecting early cases, treating them, and to their partners, appropriate and timely.
• prevent recurrence: through specific advice, during which the guidelines are discussed together, fostering understanding and tracking of medical prescriptions and contributing more effectively to adopt safer sexual practices.

STRATEGIES FOR CONTROL

• PREVENTION: prevention, basic strategy for controlling the transmission of STDs and HIV, will be through the information given to the general population and educational activities that focus: risk perception, changes in sexual behavior and the promotion and adoption of preventive measures with emphasis on proper use of condoms. Counseling activities for people with STD and its partners during the service are fundamental, in order to seek that individuals understand the need for greater care, protecting themselves and their partners, thus preventing the occurrence of new episodes. It should always emphasize the association between STDs and HIV infection. Also must-stimulating treatment adherence, explaining the existence of asymptomatic or mildly symptomatic cases also susceptible to serious complications. The promotion and distribution of condoms must be due to all the services they provide such assistance. Thus, assistance can constitute a privileged moment of prevention.
• DETECTION OF CASES: as important as diagnose and treat as early as possible symptomatic carriers is to perform the detection of asymptomatic carriers. Among the strategies that can address this important gap are the asymptomatic STD traces, particularly syphilis, gonorrhea and chlamydia in pregnant women or adolescents in specific services, such as those who perform gynecological care, especially family planning, maternal and child services and prenatal care, and preventive services for cervical-uterine cancer. Some changes in the orientation of health professionals so that they will make comprehensive care users are of fundamental importance because, with it, individuals at risk would have an opportunity for counseling and / or diagnosis.
• IMMEDIATE TREATMENT: The treatment should be instituted at the time of consultation, preferably with medication orally and in a single dose, or with the least possible number of doses. The use of flowcharts some developed, tested and validated since, provides the possibility of immediate treatment and immediate break of the transmission chain. In this approach are searched symptoms and / or signs, grouped, to provide a diagnosis of the syndrome. It will seek treatment, then, the most common etiological agents in the syndrome under study. For this type of assistance is properly implemented must also include the collection of material that will ensure the etiologic diagnosis in local or reference laboratory, counseling for risk reduction, partner treatment guidelines for adherence to the fractionated treatments, promotion and distribution condoms.

The PROPER MANAGEMENT STD CASES

STD patients should receive care and treatment immediately. The wait in long lines and the possibility of appointment for another day, associated with lack of medicines, are perhaps the main factors that lead to seeking attention directly to the clerk of pharmacy. In itself, the immediate care of a STD is not just a curative action, but also, and primarily, a preventive action of HIV transmission and the emergence of other complications.

• SCREENING: this model is considered extremely desirable to have a private screening service that is performed by health care professionals adequately prepared for this purpose.
• WAITING: waiting time should be used for health education through educational videos, advisory group activities, including other issues of health and citizenship.
• MEDICAL CONSULTATION: beyond the history and physical examination at this point must be made ​​collections of material from the secretions and lesions for laboratory examination; the material for the Pap smear should be collected only after execution of the STD healing which led to the consultation.
• NURSING CONSULTATION: the participation of nurses and other health professionals should be encouraged at all stages of care. The counseling, detection of risk situations and the health education of people with STD and its partners are activities in which these professionals should act. Exceptionally nurses can prescribe medications and apply established in public health programs and routine approved by the health institution (according to the Professional Practice of Law No. 7,498 / 86 of June 25, 1986 and regulated by Decree No. 94406 of 8 June 1987).
• ADVICE: this is an activity that should be present throughout the service and not rely on just a professional. The doctor's figure is extremely important in counseling as well as the consistency of the information to be provided by all staff. All professionals involved in attending should participate in the counseling process.
• COMMUNICATION TO THE SEXUAL PARTNERS: partners shall be considered for purposes of communication or call, individuals with whom the patient was related to sexually in the last 30 days. The use of cards to inform the sexual partners is desirable. According to the possibilities of each service, other activities can be developed. It is essential that the partners of pregnant women with syphilis who do not heed the call to active treatment are searched.

APPROACH STD CARRIER

The care of patients with STDs has some peculiarities. It aims to break the chain of transmission in the most effective and immediate way possible. It also aims to avoid the complications of (s) DST concerned, and the immediate cessation of symptoms.

The aim of this service is to try to provide, in a single query: diagnosis, treatment and appropriate counseling. There is no impediment for laboratory tests are procured or offered. The conduct, however, you should not rely on time-consuming realization processes and / or interpreting results. Does not mean that the laboratory is unnecessary, in contrast, has increased its role mainly in health care facilities more complex, which serve as sources for defining the epidemiological profile of the different STDs and their sensitivity to recommended medications.

Specific flowcharts, already developed and tested, are tools that assist the professional who performs the service in making decisions. Following the steps of the flowcharts, professional, though not expert, you will be able to: determine a syndromic diagnosis, implement prompt treatment, providing counseling to encourage adherence to treatment, to reduce risks to the summons, counseling and treatment its partners, promotion to encourage the use of condoms, among other things.

The flow charts include a number of polygons decision and action that contain the basic information necessary for the management of patients.

For using the flowchart, the professional identifies the corresponding polygon the clinical problem that is on top of the table and follows, step by step, taking the necessary decisions in accordance with the clinical findings.

After the flowchart of each syndrome, shows the corresponding notes to each polygon decision and action. These notes, albeit essential part of the flow chart, are too detailed to be included in polygons.

More specific information about the diseases covered by each syndrome will be offered immediately after the clarification notes of each flowchart. Information on STDs that are not part of the syndromes will be presented in later chapters.

The physical examination and the patient's medical history and their sexual contacts should constitute the main elements of STD diagnoses, given the difficulty of immediate access to laboratory tests. The doctor, and even other health professionals should know the main anatomical and functional aspects, both male and female body, to be able, together with the clinical history, making a diagnosis of major syndromes presumption (syndromic approach) or diseases transmitted by sex, remembering that, in women, many STDs can present themselves as asymptomatic form during variable period of time.

Importantly, get reliable information to perform a consistent history and implies the need to build a relationship of trust between the health professional and the individual in attendance.To this end, the professional must keep in mind that in the healthcare context of STDs, sexuality issues, loyalty, pleasure, displeasure, violence, concept of risk, sickness, health and others, are presented in many different ways, according to the story of each of the partners (patient and professional), its socioeconomic environment and your personality.

We know that STDs imply internal forum practices and result from the exercise of sexuality. Thus, professionals have the unique opportunity to discuss aspects of intimacy of one's life in service and therefore need to be clear about the sexual values ​​of the patient, as well as their own values. Thus, prejudice attitudes, judgments and enforcement actions may be avoided, and despite any differences, the dialogue will be ensured.

Otherwise, negative effects may occur, for example, omission of information necessary for the diagnosis or unconcerned about the actual severity of the disease or, on the other hand, exaggerating it, causing in this way, unnecessary troubles or even misfits marital.

In this sense we understand that the patient should be seen as a whole, made up of feelings, beliefs, values, ways these determinants of risky practices and attitudes of the prescribed treatment. Their organic behavior also is not restricted to the genitals; remember that other diseases (eg .: diabetes, skin diseases, immunodeficiencies, etc.), nutritional status and drug use can interfere in the diagnosis and treatment of STDs.

In attendance motivated by DST, health professionals should include thorough clinical and genital examination that includes a search for other STDs, education for risk reduction, guidance on hygienic care, offer of HIV testing, counseling, encouragement of adherence to treatment, promotion of condom use, inviting sexual partners and the notification of the case;whenever possible should be done to research and observation findings that can identify other diseases, through: general inspection, blood pressure control, palpation of breast, rectal;the cytology of the cervix should be performed when indicated and when they return from the patient.

AS DST AS A PRIORITY

PHYSICAL EXAMINATION

Observe skin, mucous membranes and palpate the lymph nodes of all body segments (head, trunk and limbs), particularly the palms, soles, oropharyngeal mucosa and genitals. Any injuries (ulcerated or not, in low or high relief, hyperemic, hyperchromic, circular, irregular, Circinate, etc.), abdomen, back, scalp and mainly in the perineal region, should be noted and correlated with the story in question .

Diseases such as syphilis can have, besides the genital region, other sites of infection. Gonorrhea can present different forms of the disease including non-genital regions (ex .: pharyngitis, osteoarthritis, conjunctivitis, peri-hepatitis, etc.). Erythema multiforme and headache may accompany the lymphogranuloma venereum.

As these observations, many other could be made, since the STI are to be sought for individual signals, but by a set of clinical data and information that may suggest the diagnosis.

MALE GENITAL EXAMINATION

For better inspection of both the inguinal region and the external genitalia, the patient should be standing with legs apart, and the clinical sitting. For the anorectal region, the patient should bend forward, pushing the buttocks with his own hands or, better still, lying in the lateral position with light at trunk flexion and thigh not leaning on the table.

Observe and palpate nodal sites and any other tumors, ulcerations, fistulas, fissures, etc. Notice possible deviations of the penile shaft, anomalous openings of the urethra, testicular asymmetry, inflammation of the scrotum. Wherever possible, the carry look for rectal tumors and protrusions, and prostate changes.

GENITAL EXAMINATION FEM

By own feminine characteristics, the gynecologist or clinician will need to count on the full cooperation of the patient. Therefore, you should capture your confidence, describing all the procedures to be performed, emphasizing the fact that all the material being used is sterile. The examination should be performed with the patient in gynecological position.

In the static test must be observed the arrangement of the hair, anatomical conformations (large and small labia, clitoris, hymen, pubic mound, perineum, anal verge), dystrophies, dyschromia, tumors, ulcers, etc.

For the dynamic test procedure to use, disposable gloves; should place the index and middle fingers in the region corresponding to the Bartholin glands (at approximately 5:07 hours) and to traction them down and out. Thus it can be half-open the vulva, which will be completely exposed, requesting to the patient to increase intra-abdominal pressure.

The speculum examination should be done after a brief explanation of the instrument to the patient, placing the speculum always sterilized with an inclination of 75, pressing the posterior vaginal wall, using the index and middle fingers to expose the vaginal opening (avoiding trauma urethra and bladder); observing coloration and vaginal folding, besides the appearance of the cervix, particularly in the cervical mucus; noting the presence or absence of secretions, tumors, ulcers and rupture; correctly perform the collection of material for laboratory analysis when in the presence of secretion of vegetating or ulcerated lesions. Then make the cleaning of external orifice with acetic acid 5% and make the Schiller test (lugol) to highlight cervical lesions and ectopia. Not having vaginal and / or cervical discharge, or after treatment of secretions or injuries, collecting material for Pap smear, when indicated.

Removal of the speculum should be as careful as its placement, avoiding holding the neck between the speculum blades or withdrawing the same fully open, which will cause pain and urethral trauma. During the retreat, slowly and carefully, observe the vaginal walls. When available the device, perform colposcopy watching all genitalia, including ectocervix, vagina, vulva and anus.

Note: The samples of materials must be made before any lubrication or cleanliness, should be avoided, thus placing the speculum petrolatum.

The vaginal ring should also be previously explained to the patient and performed with sterile glove (no need to have the surgical standard). Initially you must use your index finger to depress the rear perineum, which will contribute to the relaxation of muscles. Is introduced then the middle and index fingers (pre-lubricated), seeking to feel the vaginal elasticity, presence of tumors and / or bulges, consistency and neck size and openings of the cervical canal.

Moving the arms to either side, if pulls them off and cardinal ligaments may be evident inflammatory processes.

Only after all these maneuvers is that one must play with the other hand the abdominal wall of the patient, always respecting the respiratory movements and taking advantage of the expiration for deep palpation.

Vaginal hand pushes the cervix and the uterus up to the bottom of it can be palpated between the abdominal and vaginal hand. During palpation, note size, consistency, mobility, regularity of their shape, the angle to the cervix and the vagina and the possible sensitivity of the patient.

The accompanying regions are palpated by inserting the vaginal fingers sideways on his lap, to the bottom of the fornix, and pulling the structures in the pelvis with the abdominal hand.Associated structures (broad ligament, tube and ovary) are palpated between the two hands. These structures can not be palpable, especially in women after menopause or obese.Generally, the tubes are not palpable, unless they are augmented. One should look for masses and changes in sensitivity. The size, shape, consistency and sensitivity of any mass must also be determined.

The rectal, when necessary, shall be explained to the patient, carried out with use of lubricant. Facilitates the examination ask the patient to strength during insertion of the examiner finger. -Palpates the anal canal looking mass. Using the same technique abdomino-vaginal, pelvic structures are palpated again. Should pay special attention to retrovaginal septum, the uterossacrais ligaments, the cul de sac and later fundus. It is during this examination that best meet masses of Douglas' pouch.

RESEARCH OTHER STD

The associations between different STDs are frequent. Noteworthy is currently the relationship between the presence of STDs and the increased risk of HIV infection. 
The compliance with all the steps of the history, physical examination and collection of secretions and material for the realization of etiological diagnosis, offering to perform the serological HIV diagnosis and counseling should be part of the routine. However, remember that the examination for detection of HIV antibodies must occur if the professional feel qualified to perform pre and post-test.

ADVICE

Counseling is understood as a "process of individualized active listening and customer-centric. It requires the ability to establish a relationship of trust between the parties, aimed at rescuing the client's internal resources so that he himself has been able to recognize themselves as subjects of their own health and transformation "(National STD / AIDS. - MS 1997 )

Seen as an important tool for breaking the transmission of STDs chain, counseling helps the patient to:

• understand the relationship between their behavior and the health problem that is presenting,
• to recognize the resources you have to take care of their health and prevent new infections. 
  This practice presupposes the recognition by the professional that success to be achieved depends on the combined action of both parties (professional and patient). Therefore implies the active participation of the patient in the therapeutic process and in promoting a dialogue in which the message is contextualized to the characteristics and experiences of the individual in attendance. The demarcated idea in the counseling process is EXCHANGE:
• on the one hand there is the professional with his technical scientific knowledge, beliefs, values ​​and possibilities and limits in handling / managing each case, and
• On the other hand there is the patient with their knowledge, beliefs, values ​​and their possibilities and limits in adopting preventive measures and follow medical prescriptions.

ADVICE OBJECTIVES

To the extent that in the counseling process, the "demand" of the patient, as understood their needs, questions, concerns, fears, anxieties, etc., related to your health problem is identified and accepted, the development becomes possible a relationship of trust and promoting emotional support. Thus, the patient's stress level is reduced, providing the conditions to achieve the following objectives:

• exchange information on STDs, HIV and AIDS, its modes of transmission, prevention and treatment;
• conduct risk assessment, allowing the understanding / awareness of personal risk of infection for the current STD and HIV;
• identify the limits and possibilities for the adoption of preventive measures, encouraging self-care and partner;
• promote adherence to treatment; and
• foster communication and treatment (s) of partner (s) sex (s).

INDIVIDUAL COUNSELING AND COLLECTIVE

Counseling can be done both in groups and individually. The collective approach common issues expressed by participants should guide the content to be addressed. In this sense, the group's demand identification is critical.

In the group, people have the opportunity to resize their difficulties to share doubts, feelings, knowledge, etc. In some circumstances, this approach can cause relief from the emotional stress experienced by patients. The group dynamics can also encourage the individual to realize their own demand, to recognize what you know and feel, encouraging their participation in subsequent individual assistance. The waiting room groups can be made an example of this approach, as well as optimize the time the user spends on health care.

It is important, however, that the trader is aware to realize the limits that separate the issues to be addressed in the group space of those relevant to the individual service.

WHO DOES ADVICE?

All health team members should be able to develop counseling. It is essential that the person performing this activity has updated and technically correct information on STD / AIDS.Another important aspect for the advice to develop properly is to adopt an attitude of host valuing the patient know, think and feel about their health problems, thus facilitating the formation of the essential bond of trust throughout the process.

It is up to the health service staff work in a harmonious and integrated manner and organize itself in the most convenient way to that counseling be developed during the process of service users.

Anyway, so the advice is feasible, professionals must recognize their own limits, knowing that they can not respond to all, thus enabling an "encounter between human and professional human patients."

BASIC ADVICE PROCEDURES

• reaffirm the confidentiality and secrecy of the information provided;
• clearly identify the customer demand;
• provide emotional support to the customer;
• facilitate the client expression of feelings;
• identify the beliefs and customer values ​​about STDs, HIV and AIDS;
• use language compatible with the client's culture;
• exchanging specific information on (s) presented DST (s);
• assess the client its history of other STDs and risky situations that culminated in this STD;
• reinforce the need to adopt safer practices for risk reduction;
• explain the complications of not doing the treatment, or treatment is incomplete or self-medication;
• reinforce the need for return to service if there is no improvement or whenever present any symptoms;
• reinforce the need for treatment of sexual partners;
• exchange information on STDs and HIV and AIDS, its modes of transmission, prevention and treatment, with emphasis on client risk situations;
• help the client to evaluate and understand their risks of HIV infection and other STDs;
• identify barriers to changing risk situations;
• contribute to the development of a viable plan for risk reduction;
• explain the benefits and demonstrate the correct use of condoms;
• evaluate possible difficulties regarding the use of condoms and overcoming;
• evaluate and recommend the possibility of other safe sex practices;
• help the client to recognize their responsibilities and possibilities to deal with their problem;
• remember that alcohol and other drugs, legal or illegal can change the perception of risk;
• foster self-esteem and customer confidence;
• promote the deconstruction of stigmas, myths and prejudices related to STD and HIV and AIDS;
• encourage the dissemination of guidance received;
• refer the client to other support services, including community support groups where necessary;
• emphasize the relationship between STD and HIV and AIDS, particularly the fact that a DST facilitate HIV transmission, whatever it may be;
• offer HIV testing and pre and post-test.

ADVICE ANTI-HIV PRE-TEST

• reaffirm the voluntary and confidential nature of the testing;
• review with the client and whether or not the test;
• check previous history of testing and risks;
• exchange information on the test system and the concept of "window period";
• exchange with customer information on the meaning of possible test results;
• reinforce to the client the difference between HIV and AIDS;
• consider with the client the impact on their lives of the possible test results;
• probe which emotional and social support available to the client (family, partners, friends, work, etc.);
• consider with the potential customer emotional reactions in the waiting period of the test result;
• reinforce the need for the adoption of safe practices to HIV also will be shown.

ADVICE AFTER TEST BEFORE NEGATIVE RESULT:

report that a negative result means that the person is not infected or has been infected so recently that did not produce necessary antibodies to detect the used test;

assess the client's ability to be in "window period" and require a new test;

remember that a negative result does not mean immunity;

reinforce safe practices already adopted or to be adopted by the client to HIV;

enhance the benefits of exclusive use of equipment for injection drug use and demonstrate the correct method of cleaning and disinfecting syringes and needles, if needed.

ADVICE AFTER TEST BEFORE POSITIVE RESULT

• allow the time necessary for the customer assimilate the impact the diagnosis and express their feelings;
• talk about feelings and concerns, providing the necessary emotional support;
• be attentive to the proper management of common feelings, such as anger, anxiety, depression, fear, denial, and others;
• demystify feelings that associate HIV / AIDS with guilt, punishment, rejection, degeneration, death, and others;
• resume a positive result means that the person is carrying the virus, and may or may not be developed with the disease;
• emphasize that even being an asymptomatic carrier can transmit the virus to others;
• reinforce the importance of medical monitoring, noting that the infection is treatable;
• reinforce the need for the adoption of safe practices for reducing the risk of re-infection with HIV and other STDs;
• enhance the benefits and demonstrate the correct use of condoms, if there are still doubts;
• enhance the benefits of exclusive use of equipment for injection drug use and demonstrate the correct method of cleaning and disinfecting syringes and needles, if needed;
• emphasize the need for results to be communicated to sexual partners offering help, if requested;
• advise on the need for the partners undertake HIV testing;
• define customer support services needed, including community support groups;
• in pregnant woman case explain:
• forms of vertical transmission, which can occur during pregnancy, childbirth or breastfeeding;
• how to minimize the chances of vertical transmission;
• the transmission of maternal antibodies and the seroconversion process in the newborn;
• the risks of breastfeeding; and
• the need to complete the testing of all children born after the infection or, in case of doubt after 1980.

ADVICE AFTER TEST BEFORE INDETERMINATE RESULT:

explain that an indeterminate result may mean: a false positive due to biological reasons or a true positive from a recent infection whose antibodies are not fully developed;

strengthen the adoption of safe practices for reducing risks of infection by HIV and other STDs;

enhance the benefits and demonstrate the correct use of condoms;

enhance the benefits of exclusive use of equipment for injection drug use and demonstrate the correct method of cleaning and disinfecting syringes and needles, if needed;

guide the performance of a new collection to retake the test in the period defined by the laboratory; and

consider with the potential customer emotional reactions in the waiting period of the test result and reference to psychological support if necessary.

CONDOMS

Although dual function (contraceptive and prophylactic), the condom has always been more directly linked to the prevention of sexually transmitted diseases (STDs). Before arise contraception as "pill", the IUD, diaphragm and surgical sterilization, for example, condoms (along with the practice of coitus interruptus) seems to have played an important role in the regulation of fertility, in view of reduced alternative birth control then available. However, the main purpose of its use was the prevention of STDs. This applies to young people and adolescents who initiated sexual life (usually with sex workers) as well as adults and married men in extramarital affairs.

From the 50s, with the development of penicillin and other antibiotics effective, practices and preventive behaviors regarding STI it was becoming increasingly less adopted. To this also contributed the rapid evolution of customs (which introduced, in most societies, greater sexual freedom), discouraging the use of services of sex workers. In addition, the emergence of the contraceptive pill allowed women to have power over their reproductive function, for the first time in history. No doubt these were decisive factors for the use of condoms became gradually unimpressive especially in developing countries.

In Brazil, condoms are rarely used, either as contraception or as a prophylactic method of STD / AIDS. In national surveys conducted with women of childbearing age (MIF), that is, in the age group 15-44 years married or in union, condom use was reported by only 1.7% or 1.8% of all users of contraceptive methods. However, these results seem to be underestimated.Indeed, local surveys along the sexually active men, aged between 15 and 24 years old, detected use rates of condom that ranged from 12.5% ​​to 32.4% (in Rio de Janeiro, respectively, for young people united and not attached); 14.7% to 34.1% (in Curitiba); and from about 18% to 40.4% (by Reef). In the city of Campinas (São Paulo) survey of 305 men 18 to 30 years (singles, mostly), reached similar results: 75% of respondents reported sexual intercourse that occurred during the 30 days preceding the survey, but only 29.8% of them reported consistent condom use.

Anyway, these levels of condom use, especially in the era of AIDS are still very low. In a way, this could be justified by factors such as: "to have a stable relationship," "did not keep casual relationships or promiscuous", "have a good knowledge about the current partner" and "partnership is using another contraceptive method," as It was detected in several qualitative research. However, the emergence of AIDS, highly lethal disease, for which there is still no preventive medication, impose changes in behavior, attitudes and sexual practices, both by individuals and society as a whole.

Undoubtedly, the growing possibility of exposure to HIV, the exercise of sexuality again require care transmitted diseases and, in this case, preventive measures should be taken by all individuals, regardless of age or gender factors. Even people who, because they want to have children because they are sterile or have undergone surgical sterilization, or even as they were already out of the reproductive period did not need to resort to using contraception, also find themselves today forced to use in their sexual practice a barrier method designed to minimize the risk of exposure to HIV.

As a result, AIDS came redeveloped an old method, which levels of use, worldwide, had been steadily declining since the mid 50. This rapid change, however, also requires changes in attitude on the part of individuals, particularly those referring to the acceptability and effective use of a method (contraceptive and prophylactic) still regarded as old-fashioned, besides being stigmatized because very often it is associated with illicit sexual relationships and / or promiscuous, as well as sexual practices also considered high risk.

The use of condoms, both male and female, for sexually active people, is the most effective method for reducing the risk of transmission of HIV and other sexually transmitted agents.Your safety, however, depends on the use of technique and its systematic use in all sexual relations.

Male Condom

• It should be stored away from heat, observing the integrity of the package as well as the expiry date;
• should be placed before the penetration, obtained after penile erection;
• the existing receptacle at the end of the condom must be tightened during loading, removing all air from inside;
• still holding the tip of the condom, unroll it to the base of the penis;
• They should be used only for aqueous-based lubricants for the use of oily lubricants (such as Vaseline or edible oils) damages the latex, increasing the risk of rupture;
• in the case of rupture, the condom should be replaced immediately;
• after ejaculation, withdraw the penis is still erect, holding the condom at the base so that no sperm leak; and
• the condom should not be reused and must be disposed of in the garbage (not in the toilet) after use.

Constant users of male condoms point as risk factors for rupture or leak

• poor storage conditions;
• Failure to observe the expiration date, 
  insufficient vaginal lubrication;
• anal sex without proper lubrication;
• use of oily lubricants;
• presence of air and / or absence of sperm collecting space for the tip of the condom;
• inadequate size in relation to the penis;
• loss of erection during sex;
• contraction of the vaginal muscles during withdrawal of the penis;
• withdrawal of the penis without firmly hold the base of the condom;
• use of two preservatives (due to friction occurring between them); and
• use of the same condom during intercourse extended.

Female condom

• It should be stored away from heat, observing the integrity of the package as well as the expiry date;
• It should not be used together with condoms;
• unlike the male condom, the female can be placed up to eight hours before intercourse and removed with ease after intercourse, preferably before the woman get up, to prevent sperm drain the inside of the condom;
• the female condom is lubricated, however, if necessary, should be used indoors, only water-based lubricants because the use of oily lubricants (such as Vaseline or cooking oil) damages the latex, increasing the risk of rupture;
• to put it correctly, you should find a comfortable position (standing with one foot on a chair, sitting with knees apart, crouching or lying down); the movable ring must be pressed and inserted into the vagina; with the index finger it should be pushed as deep as possible to reach the cervix; fixing the ring (outer) should be about 3 cm out of the vagina; during penetration of the penis must be guided to the center of the outer ring;
• a new condom each new relationship must be used.

Regular condom use can lead to improvement in the technique of use, reducing the frequency of rupture and leak and, consequently, increasing their effectiveness.

Condoms should be promoted and offered to patients as part of routine care.

CONCEPT

1. Infectious Disease, often sexually transmitted, also known as condyloma acuminate, genital warts or rooster combs.

ETIOLOGICAL AGENT

The human papillomavirus (HPV) is a non-cultivable DNA virus papovavirus group. Currently there are more than 70 known types, 20 of which can infect the genital tract. They are divided into 3 groups according to their potential carcinogenicity. The types of high oncogenic risk when associated with other co-factors, is related to the development of intraepithelial neoplasia and invasive cervical cancer. 
Association of 15 types of HPV neoplastic diseases of the cervix and its precursors.

2

Classification connected function with serious injuries	HPV Types	Association with cervical lesions
Low risk	6, 11, 42, 43 and 44	20.2% in low-grade CIN, virtually nonexistent in invasive carcinomas
Intermediate risk	31, 33, 35, 51, 52 and 58	23.8% of high-grade CIN but only 10.5% of invasive carcinomas
High risk	16	47.1% for high-grade CIN or invasive carcinoma
	18, 45 and 56	6.5% of high-grade CIN and invasive carcinoma 26.8%

CLINICAL

Most infections are asymptomatic or unapparent. May present clinically as exophytic lesions. The infection can also take a form called subclinical, visible only under magnification after application techniques and reagents such as acetic acid. Furthermore, this virus is capable of establishing a latent infection in which there are identifiable clinical or sub-clinical lesions, its DNA is detectable only by molecular techniques in infected tissues. It is not known at the time that the virus can remain in that state, and which factors are responsible for the development of lesions. For this reason, it is not possible to set the minimum interval between the contamination and the development of lesions, which may be weeks, decades. 
Some prospective studies have shown that in many people, the infection will have a temporary nature, and can be detected or no. The virus can remain for many years in a latent state, and after this period, cause further injury. Thus, HPV lesions of recurrence is more likely related to the activation of "reservoirs" virus themselves than to reinfection by sexual partner. The factors that determine the persistence of the infection and its progression to high-grade intraepithelial neoplasia (moderate dysplasia, severe dysplasia or carcinoma in situ) are viral types present and co-factors, including, immune status, smoking and other less importance.

The warts depending on the size and anatomical location, can be painful, friable and / or itchy. When present in the cervix, vagina, urethra and anus, may also be symptomatic. The intra-anal warts are prevalent in patients who have had receptive anal intercourse. Already the perianal can occur in men and women who have anal penetration history. Less can often be present in extragenital areas such as conjunctival, nasal mucosa, oral and laryngeal.

In clinical form lesions may be single or multiple, localized or diffuse and variable size, being located more frequently in men, the glans, balano-preputial furrow and perianal region, and in women, the vulva, perineum, perianal region, vagina and cervix.

The types 16, 18, 31, 33, 35, 45, 51, 52, 56 and 58, are occasionally found in the clinical form of infection (genital warts) and has been associated with external lesions (vulva, penis and anus), with intraepithelial neoplasia or invasive cervix and vagina. When the external genitalia are associated with carcinoma in situ squamous cell Papulosis bowenoid, Erythroplakia of Queyrat and Bowen's disease of the genitalia. Patients who have genital warts can be infected simultaneously with multiple HPV types. The types 6 and 11 are rarely associated with invasive squamous cell carcinoma of the external genitalia.

DIAGNOSIS

The diagnosis of condylomata is basically clinical can be confirmed by biopsy, although this is rarely necessary. This procedure is useful when:

• there is diagnostic uncertainty or suspected neoplasia (pigmented lesions, hardened, fixed or ulcerated);
• the lesions do not respond to conventional treatment;
• the lesions increase in size during or after treatment;
• the patient is immunodeficient.

In these cases it is recommended to performing various biopsies with material taken from several different lesion sites. The cervical lesions, subclinical, are usually detected by cytology and should be evaluated by colposcopy and directed biopsies.

The definitive diagnosis of HPV infection is done by identifying the presence of viral DNA by molecular hybridization tests (in situ hybridization, PCR, hybrid capture). The diagnostic Pap smear is not always correlated with the identification of HPV DNA. The cell changes caused by HPV in cervical have the same clinical significance than those seen in mild dysplasias or intraepithelial neoplasia grade I. More recently, both conditions have been termed interchangeably as squamous intraepithelial lesion low grade (Low Grade Squamous Intraepithelial Lesion - LSIL), with great chance of regression without treatment. There are tests that identify various types of HPV but it is unclear its value in clinical practice and the clinical management decisions should not be made based on these tests. It is also not recommended screening for subclinical HPV infection through these tests.

TREATMENT

The main goal of treatment of HPV infection is the removal of symptomatic warts, leading to injury-free periods in many patients. Genital warts are often asymptomatic. No evidence indicates that currently available treatments eradicate or affect the natural history of HPV infection. The removal of the wart may or may not reduce their infectivity. If left untreated, the warts may go away, remain unchanged, or increase in size or number. No evidence indicates that treatment of condyloma prevent the development of cervical cancer. 
The available treatments for warts are cryotherapy, electrocoagulation, podophyllin, trichloroacetic acid (ATA) and surgical excision.

Most patients have 1-10 warts, which account for most treatment modalities. 
With the method chosen, none of the available treatments is superior to others, and no treatment is ideal for all patients or for all warts.

Factors that may influence the choice of treatment are the size, number and location of injury, and their morphology and patient preference, cost, availability, convenience features, adverse effects, and the experience of the healthcare professional.

In general, warts located on wet surfaces and / or in intertriginous areas best respond to topical therapy (ATA podophyllin) that warts on dry surfaces.

Plan treatment with the patient is important because many patients require more than one therapy session. One should change treatment option when a patient does not improve substantially after three applications, or if the warts do not disappear completely after six sessions. The balance between risk and benefit of treatment should be analyzed during the process to avoid overtreatment.

Complications rarely occur if treatments are used correctly. Patients should be warned of the possibility of hypo or hypertrophic scars when destructive methods are used. They also may result, although rarely, in hypertrophic or depressed areas, especially if the patient has not had enough time to complete healing before a new treatment session. More rarely, treatment can result in crippling pain syndromes, such as vulvodynia or soreness of the treated area.

Lesions on the external genitalia

• Podophyllin 10-25% alcohol solution or tincture of benzoin: to apply a small amount on each wart and let dry. To avoid the possibility of complications associated with its systemic absorption and toxicity, some experts recommend that you use up to 0.5 ml in each application or to limit the area treated up to 10 cm2 per session. Others suggest that the solution is removed by rinsing the treated area 1-4 hours after application to reduce irritation at the site. Repeat if necessary weekly. Never use during pregnancy. The podofilina contain a number of substances with antimitotic action. However, the proportion of these substances varies considerably between preparations. The validity and stability of the preparations are unknown. The carelessness to allow the patient to wear before the complete drying of the solution can spread it in neighboring areas leading to a large area of ​​local irritation. Its absorption in large quantities can be toxic to the heart, kidneys and nervous system.
• Trichloroacetic acid (ATA) 80-90% solution in alcohol: Apply small amount only in condylomas and left to dry, after which the lesion assumes white appearance. If too much is applied, may remove excess sprinkling talc or sodium bicarbonate. Repeat if necessary weekly. The ATA is a caustic agent that promotes destruction of warts by chemical coagulation of its protein content. Despite its wide use, it has not been investigated thoroughly. The ATA solutions are very fluid, comparable to water, and can spread rapidly if applied in excess, causing damage to adjacent areas to injury. It should be applied carefully, leaving it dry even before the patient change their position so that the solution does not "drain" to other locations. If the pain is severe, the acid can be neutralized with soap or sodium bicarbonate. This method can be used during pregnancy, when the injured area is not too extensive. The contrary, it must be associated with surgical excision (you see specific item)
• Electrocautery or electrocoagulation or electrofulguration: This method uses an electrocautery to remove or flare isolated lesions. Requires specific equipment and local anesthesia.Does not apply in vaginal lesions, cervical and anal, since the depth of the control effect is difficult and may lead to extensive tissue necrosis and stenosis in tubular structures, such as anal canal and vagina.
• Criocauterização or Cryotherapy or cryotherapy: this method promotes thermal destruction of chilled metal devices for CO2 (criocautérios). Cryotherapy depends on specific equipment and eliminates the warts to induce thermal lysis. It is useful when there are few lesions or in very keratinized lesions and rarely requires anesthesia. More may be required for a therapeutic session, an interval of 1 to 2 weeks. Its biggest drawback is to require reasonable level of training without which the warts are often treated excessively or insufficiently, resulting in reduction of its effectiveness and greater chance of complications. Despite local anesthesia not be required routinely, could facilitate the processing if there are many injuries or extensive area involved.
• Surgical excision: it is suitable method for the treatment of few lesions on an outpatient basis, especially when it is desirable histopathology of the specimen. Surgical excision have the advantage that, as well as electrocautery, remove lesions in one treatment session. However, training is needed, local anesthesia and specific equipment, as well as lengthen the time of consultation. Warts can be removed by a gentle tangential incision with scissors, scalpel or a curette. Since most lesions are exophytic, these methods result in a wound which involves the superficial portion of the dermis. Hemostasis can be achieved by electrocoagulation. Typically the suture is not necessary. This method brings benefits to patients who have large numbers of injuries or extensive affected area, or even in resistant cases to other forms of treatment.

Vegetative lesions of the cervix

In the presence of vegetative injury to the cervix should exclude the possibility that this is an intra-epithelial neoplasia before starting treatment. These patients should be referred to a colposcopy service for differential diagnosis and treatment. Vaginal lesions

• ATA 80-90%: Apply only on injuries. Allow to dry before removing the vaginal speculum. Do not apply over large area in a single session to avoid vaginal stenosis. It can be applied weekly, if necessary. For removal of the acid when applied in excess, it is recommended that the application of sodium bicarbonate or talc.
• Podophyllin 10-25%: applying to the lesion and allow to dry before removing the speculum. Treating at most 2 cm2 per session, repeating the application at weekly intervals if necessary. Some experts are opposed to its use in vaginal lesions because of their toxic effects and increased ability to vaginal absorption. Do not use during pregnancy.
• Note cryotherapy not apply for vaginal lesions, because of the risk of vaginal perforation and fistula formation.

Injuries at the urethral meatus

• ATA 80-90%: Apply only on injuries. Allow to dry before allowing contact of the treated area with normal mucosa. Do not apply over large area in a single session to avoid stenosis. It can be applied weekly, if necessary. For removal of the acid when applied in excess, it is recommended that the application of sodium bicarbonate or talc.
• Podophyllin 10-25%: apply on injuries and allow to dry before allowing contact of the treated area with normal mucosa. It can be applied weekly, if necessary. Do not use during pregnancy.

Anal injuries

• MINUTES 80-90%. Apply only on injuries. Allow to dry before allowing contact of the treated area with normal mucosa. Do not apply over large area in a single session to avoid stenosis. It can be applied weekly, if necessary. For removal of the acid when applied in excess, it is recommended that the application of sodium bicarbonate or talc.
• Surgical excision.
• Note: the conduct in front of anal mucosa lesions should be decided by an expert.

Oral lesions

• Surgical excision.

FOLLOW-UP 
After the disappearance of warts, you do not need control. Patients should be advised of the possibility of recurrence, which often occurs in the first three months. As we do not know the sensitivity and specificity of self-diagnosis, patients should be examined three months after the end of treatment. Further tests at shorter intervals, can be useful for:

• document the absence of warts;
• control or treat complications of treatment; and
• strengthen the guidance and advice on the prevention of HIV and other STDs.

Women should be counseled on the need to submit to the screening of pre-invasive diseases of the cervix, at the same frequency that women not infected with HPV. The presence of genital warts without macroscopic lesion or cervical colpocitológica suspicion (Papanicolaou) pre-invasive lesions, is not an indication for colposcopy.

Women treated for cervical lesions should be followed routine after treatment for gynecological exam and cytology every 3 months, 6 months; then every 6 months for 12 months and after this period, each year, there is no evidence of recurrence.

CONDUCT FOR SEXUAL PARTNERS

Examination of sexual partners has no practical use for the management of warts, because the role of reinfection in the persistence or recurrence of injury is minimal, even in the absence of treatment that eradicates the virus. Thus, the partner treatment in order to reduce its transmission, is not necessary. However, as self-examination has unknown value, sexual partners of patients with warts should be sought, as they may benefit from medical examination to assess the presence of warts unsuspected, or other STDs. These partners can also benefit from guidance on the implications of having a condyloma carrier sexual partner, especially for women, that is, the partner should be advised to undergo regular screening to pre-invasive diseases of the cervix, as any sexually active woman. As the treatment of warts does not eliminate HPV, patients and their partners should be made aware that they can be infectious, even in the absence of visible lesions. The use of condoms can reduce, but not eliminate, the risk of transmission to uncontaminated partners.

PREGNANT WOMEN

During pregnancy, the condyloma lesions can reach large proportions, either by increased vascularity, or by immunological and hormonal changes that occur at this time. 
As the lesions during pregnancy can proliferate and become brittle, many experts indicate its removal at this stage . 
. The types 6 and 11 cause laryngeal papillomatosis in infants and children 
is not known so far, the transmission route is transplacental, perinatal or postnatal. 
There is established the preventive value of cesarean section; therefore, this should not be done based only on preventing transmission of HPV to the newborn. Only in rare cases, when the lesions are causing birth canal obstruction, or when vaginal delivery can cause excessive bleeding, cesarean section may be indicated.

The choice of treatment will be based on the size and number of lesions:

• Never use Podophyllin during any stage of pregnancy.
• Small, isolated and external injuries: electro criocauterização or at any stage of pregnancy.
• And large external injuries: Resection with electrocautery or high-frequency surgical excision or by diathermy or LEEP loop (Loop Electrosurgical Procedure Excison) at any stage of pregnancy. Can result in significant bleeding and should be limited to actual injury, and limited to use by a qualified professional.
• Minor injuries, colon, vagina and vulva: electro or criocauterização, only from the 2nd quarter.
• If the size and location of the lesions are sufficient to cause obstruction and / or vaginal bleeding, you should indicate cesarean delivery.
• Although the types 6 and 11 can cause laryngeal papillomatosis in children, the risk of nasopharyngeal infection in the fetus is so low that it does not justify the indication for elective cesarean delivery.
• Women with condylomata during pregnancy should be followed with cytology after delivery.

LIVING WITH HIV

People immunosuppressed due to HIV infection, or other reasons, may not respond to treatment for HPV as immunocompetent and can happen more frequent relapses. The squamous cell carcinoma may arise more frequently in immunosuppressed, valuing the biopsy lesions in this group of patients. Treatment for these patients should be based on the same principles referred to HIV-negative.

HIGH-GRADE intraepithelial NEOPLASIAS

Patients with high-grade intraepithelial lesions (Squamous Intraepithelial Lesion High Grade - HSIL) or moderate or severe dysplasia or carcinoma in situ CIN II or CIN III, should be referred to specialized service for diagnostic confirmation, away possibility of invasive carcinoma and conducting specialized treatment. Ablative treatments are effective but the post-treatment control is important. The risk of these lesions progress to invasive carcinoma in immunocompetent patients after effective treatment, it is very low.

INFECTION BY SUBCLINICAL HPV IN GENITALIA (WITHOUT INJURY MACROSCOPIC)

Subclinical HPV infection is more frequent than gross lesions in both men and women. The diagnosis almost always occurs indirectly by observing areas turn white after application of acetic acid under colposcopic vision or other magnification techniques, and that biopsy, have cytological alterations compatible with HPV infection. They can be found anywhere in the male or female genitals. However, the application of magnification techniques and the use of acetic acid solely for screening subclinical infection by HPV is not recommended. The reaction to acetic acid is not a specific indicator of HPV infection and thus many false-positive tests can be found in low-risk populations. In special situations, some clinicians find this useful test to identify flat lesions by HPV.

In the absence of intraepithelial neoplasia, it is not recommended to treat subclinical HPV lesions diagnosed by cytology, colposcopy, biopsy tests with acetic acid or viral DNA identification tests. Often the diagnosis is questionable, and no therapy has been able to eradicate the virus. HPV has been identified in areas adjacent to intraepithelial neoplasia treated by laser and vaporized in order to eliminate infection.

In the presence of intraepithelial neoplasia, the patient should be referred to a specialist service and the treatment will be done according to the degree of the disease.

There is a simple and practical test to detect subclinical HPV infection. The use of condoms can reduce the chance of HPV transmission to uninfected partners probably (new partners). It is not known whether the infectivity of this form of infection is equal to the exophytic.

Cervical cancer SCREENING FOR WOMEN WHO HAVE OR HAVE DST

Women with a history or suffering from STDs are at increased risk for cervical cancer and other factors that increase this risk, like HPV infection. Prevalence studies show that precursor lesions of cervical cancer are five times more frequent in women with STDs than those seeking other medical services, for example, to family planning.

The Pap smear ("preventive" or Pap smear) is an effective and inexpensive test for screening of cervical cancer and its precursores.3 Although the Brazilian consensus recommends performing the smear every three years after two cervical smears consecutive negative with an interval of one year in sexually active women, it is reasonable that women with STDs are subjected to smear more often for their higher risk of being carriers of cervical cancer or its precursors. This recommendation is reinforced by data from surveys which showed that these women do not understand the real importance of cytology and often believed to have been subjected to this test when they had just been submitted to gynecological examination (two-hand touch).

Recommendations

When attending an STD, the health professional should ask about the result of your last Pap test and the time it was performed. The following should inform it of:

• the importance and the purpose of the Pap smear;
• the need for their periodic holding; and
• the places where the collections of cytology are performed when this material can not be harvested in the query itself.

If the patient has an STD did not undergo a Pap test in the last 12 months:

• the collection should be carried out as soon as the DST is controlled;
• if the DST is an HPV infection, the collection should be part of routine gynecological examination;
• the gynecological examination should be done when there is doubt, because the patient may believe that underwent this test when it actually did not. This will also be recommended when the patient does not know how to inform test result, either misinformation or have not sought its outcome, as often occurs in our midst. Any woman will benefit by receiving in writing the result of its cytology and subsequent conduct. If possible, provide copies or extracts of the result of this test the patient herself to be part of their medical documents.

Follow

Health professionals should prefer cytopathology laboratories that use Bethesda4 Classification system. If the result of cytology is abnormal, the patient should be referred to specialized service of uterine cervical pathology. In these services, the patient will undergo a colposcopy to guide biopsies and treated in accordance with the degree of precursor lesion or cervical cancer is present. In cases colpocytology concluded by the presence of LSIL or undetermined significance of atypical squamous cells (Atypical Squamous Cells of Undeterminated Significance - ASCUS), an indication of colposcopy may be delayed, especially when there is inflammation associated or cytopathologist suggests that atypical They are probably related the reaction process. These cases may include inflammation, reactive, LSIL, or, less frequently, HSIL and proper conduct would be possible to treat associated inflammatory processes and repeat cytology every 4-6 months for 2 years, until the result of three tests row are negative. If they persist atypia or suggested presence of more serious injury, only then must provide a colposcopy and directed biopsy. The cases that persist with atypia are more likely to be carriers of precursor lesions of cervical cancer. Others represent false-positive initial test or cases where there may have been spontaneous remission.

In places where there is no specialized service with colposcopy, one patient with high-grade squamous intraepithelial lesion (HSIL) should be referred for appropriate follow-up by cytology, colposcopy and directed biopsy.

Services and health care professionals who intend to carry out cytology must first establish what are the services to which women with atypia colpocytological will be referred to. The same services and professionals should also establish mechanisms by which women who do not return to get their results or kept in cytological follow-up (as the carriers of LSIL / ASCUS), fail to show up for new collections, are actively pursued.

Other important considerations

It is important to remember that:

• colpocytology is no effective screening test for STD;
• if a woman is menstruating, the collection of cytology should be postponed and the woman advised as to submit to the examination as soon as possible;
• the presence of vaginitis or colpocervicites may compromise the interpretation of cytology. In these cases the woman should be treated specifically and return to collect. However, it is unlikely that the woman return, the opportunity to sample should not be missed. In this case, excess secretion can be removed with cotton or gauze soaked in saline;
• it should be noted that in STD research, when they will be collected specimens for bacteriological diagnosis, the material for cytology should be harvested last;
• a patient with warts woman does not need more frequent collections smear than the others, except in the cases discussed above anomalies to the cytological diagnosis and immunosuppressed patients;
• hysterectomised women do not require routine screening for cervical cancer, unless the hysterectomy was sub-total or held by cervical cancer or its precursors. In these situations, the woman should be advised to maintain their grip on the specialized service that performed the surgery;
• trained health professionals and services adopt measures to ensure a good sample colpocitológica get few unsatisfactory smears. These measures include: Proper identification (s) blade, with initials of the patient and his record at the Health Unit and the packaging, full name, registration, date of collection and name of the trader who took the sample; collecting ecto and endocervical; use of endocervical brush; fixing after the smear;
• despite identify high-risk types of HPV to cervical cancer, testing for identification have discussed clinical application and, therefore, are not recommended.

Special situations

• Collection during pregnancy: Pregnant women should undergo as the other to a smear test, including careful endocervical collection as part of routine prenatal care.
• HIV-infected women: several studies have shown a higher prevalence of CIN in HIV-positive and, in these women, it is observed very short time (months) of progression to severe pre-invasive lesions and cervical cancer.

When present atypical cytology in women with HIV, these should be referred to specialized service, which will be submitted to conventional investigation by colposcopy and directed biopsy when indicated, and treated as the others. For screening of cervical cancer and its precursors in HIV-positive, you should:

• obtain prior gynecological history of diseases of the cervix;
• make full pelvic examination with Pap smear collection;
• making the smear after initial diagnosis of HIV and, if negative, must repeat it after six months.

Maintained the absence of NIC evidence, repeat the smear annually. Only women with atypia to smear should be referred for colposcopy and directed biopsy, as the already listed guidelines.

Considering the higher prevalence of CIN in HIV-positive, some women with CIN may be living with HIV still undiagnosed. Given that these women will benefit by serological diagnosis of the presence of HIV, this test must be provided after the advice all patients with HSIL (mild dysplasia, severe and carcinoma in situ, CIN II or III).