Foreign Body, Vaginal

CHAPTER 91

Foreign Body, Vaginal

Presentation

This can be a problem of both children and adults. Children may insert a foreign body and not tell their parents or may be the victims of child abuse. The patient is finally brought to the emergency department with a foul-smelling, bloody or brown purulent discharge, or pain. Vaginal foreign bodies in the adult may be a result of a psychiatric disorder or unusual sexual practices. Occasionally, a tampon or pessary is forgotten or lost and causes discomfort and a vaginal discharge.

What To Do:

Visualize the foreign body using a nasal speculum for the pediatric patient or a vaginal speculum for the adult. Consider using procedural sedation (see Appendix E) in a child or frightened adult.

Other noninvasive methods used to identify foreign bodies in young patients include pelvic sonography, plain abdominal radiography, and MRI, all of which are imperfect and can miss foreign bodies, such as those made of plastic.

Pediatric patients may be placed in the knee-chest position. While a rectal examination is being performed, the foreign body may be expelled from the vagina by pushing it with the examining finger in the rectum.

Friable foreign bodies, such as wads of toilet paper (one of the most common foreign bodies), may be flushed out using warm water or saline, an infant feeding tube, or a pediatric Foley catheter attached to a 60-mL syringe. The catheter tip is inserted into the vagina past the object, then flushed (using a moderate amount of pressure) with approximately 200 mL of fluid.

Lost or forgotten tampons can be removed with vaginal forceps that are first pierced through the finger of a polyvinyl glove, so that when the malodorous foreign body is extracted, the glove can immediately be pulled over it to reduce the odor before it is discarded in a sealed plastic bag. The vagina should then be swabbed with a Betadine solution.

In difficult cases, or when large or sharp objects are involved, young and adult patients may require general anesthesia to allow removal under direct vision. When general anesthesia is not required, conscious sedation should be considered.

With objects that are not likely to cause harm, the patient should empty her bladder and lie in stirrups in the lithotomy position. Insert a Foley catheter to break any suction between the foreign body and the vaginal mucosa. Most objects can then be grasped with ring forceps, a tenaculum, or the plaster and tongue blade method (see Chapter 71).

Reserve radiographs for radiopaque foreign bodies concealed in the bladder or urethra. Objects in the vagina are usually apparent on examination.

When a foreign body is suspected in a child but cannot be visualized, refer the patient for examination under anesthesia and vaginoscopy, which allows the identification of foreign bodies, aids in the diagnosis of other unusual conditions, as well as allows for a complete examination and an opportunity for sexual assault forensic collection.

What Not To Do:

Do not ignore a vaginal discharge in a pediatric patient or assume it is the result of benign vaginitis. Perform a bimanual or rectoabdominal examination to palpate a hard object, and then do a gentle speculum examination to look for a foreign body or signs of vaginal trauma.

Do not forget to ask about possible sexual abuse, and consult with protective services if it cannot be ruled out.

Discussion

Removal of a vaginal foreign body is generally not a problem, but when large objects make removal more difficult, use the additional techniques described for rectal foreign bodies (see Chapter 71).

Vaginal discharge in children is a common gynecologic complaint. Common sources for vaginal irritation or discharge include fecal contamination from poor perineal hygiene, spread of respiratory bacteria from hand to perineal contact, and local irritants, such as bubble bath or nylon underwear. Recommended treatments have included improved hygiene measures, avoidance of irritants, oral antibiotics, and estrogen cream.

Recurrent or persistent vaginal discharge should raise concerns of an uncertain bacterial source, possible undisclosed sexual abuse, and the possibility of a foreign body. Foreign bodies are the cause for 10% of girls presenting with a complaint of bloody discharge.

If a premenarchal girl presents with vaginal discharge that does not respond to hygiene measures and medical therapy (including antibiotics)—or if the vaginal discharge is unusual, malodorous, and/or bloody or not consistent with clinical findings—a thorough investigation to rule out a foreign body must be performed.