Retained tampon treatment. Vaginal Foreign Body: Comprehensive Guide to Evaluation, Treatment, and Management

29.08.202328.06.2023 by alexxlab

What are the common types of vaginal foreign bodies. How are vaginal foreign bodies evaluated and treated. What complications can arise from retained vaginal foreign bodies. How do healthcare professionals remove vaginal foreign bodies safely. What imaging methods are used to detect vaginal foreign bodies. How do vaginal foreign bodies present in different age groups. What strategies can improve outcomes for patients with vaginal foreign bodies.

Содержание

Common Types of Vaginal Foreign Bodies Across Age Groups

Vaginal foreign bodies can affect females of all ages, presenting in various healthcare settings from emergency departments to gynecology offices. The types of objects found often correlate with the patient’s age group:

Pediatric patients: Toys, tissue paper, and household objects
Adult women: Tampons, condoms, menstrual cups, and items used for sexual gratification
Elderly patients: Retained medical devices such as pessaries
Special populations: Prisoners and drug traffickers may use the vaginal canal to conceal illicit substances

In rare cases, postpartum patients may experience complications from retained surgical gauze, although this is uncommon due to stringent safety protocols during delivery.

Recognizing Symptoms and Presentations of Vaginal Foreign Bodies

Patients with vaginal foreign bodies may present with a variety of symptoms or may self-report the presence of an object. Common presentations include:

Pelvic pain
Vaginal discharge
Vaginal bleeding
Urinary complaints
Rectal discomfort

It’s crucial to note that these symptoms can mimic other conditions such as malignancies, sexually transmitted infections, candidal infections, and pregnancy. In pediatric patients, vaginal bleeding or discharge is the most common presenting symptom.

How do healthcare professionals differentiate vaginal foreign bodies from other conditions?

Healthcare professionals use a combination of patient history, physical examination, and imaging studies to differentiate vaginal foreign bodies from other conditions. A thorough history focusing on the timing of symptom onset, suspected objects, and associated symptoms is essential. The physical examination, including a genital exam and possibly a pelvic exam with a speculum, can provide valuable information. In cases where the diagnosis remains unclear, imaging studies such as ultrasound, X-ray, CT scan, or MRI may be employed to confirm the presence of a foreign body and rule out other potential causes of symptoms.

Evaluation Techniques for Vaginal Foreign Bodies

The evaluation of vaginal foreign bodies requires a systematic approach:

Patient history: Focus on details surrounding the initial event, including timing, suspected object, and symptoms affecting the abdomen, pelvis, and genitalia.
Physical examination: Conduct a genital exam, which may include a pelvic exam with a speculum.
Imaging studies: Consider X-ray, CT scan, MRI, or ultrasound if the diagnosis is unclear or complications are suspected.

The choice of imaging modality depends on the patient’s age, presenting symptoms, and suspected complications. For pediatric patients, transabdominal ultrasound is often preferred due to its lack of radiation exposure and less invasive nature compared to transvaginal ultrasound.

What is the sensitivity and specificity of ultrasound in detecting vaginal foreign bodies?

Transabdominal ultrasound has an overall sensitivity of 81% and specificity of 53% in detecting vaginal foreign bodies. Its accuracy improves significantly for objects larger than 5 mm in size. This makes ultrasound a more reliable option compared to X-ray, which may only detect 23% of foreign bodies. In cases where complications such as fistulas or abscesses are suspected, CT imaging may be considered for a more detailed evaluation.

Safe Removal Techniques for Vaginal Foreign Bodies

The removal of vaginal foreign bodies requires careful consideration of the patient’s comfort, the nature of the object, and potential complications. Here are some key points to consider:

Obtain informed consent before performing any pelvic examination or removal procedure.
Ensure proper equipment and personnel are available.
Use appropriate techniques based on the type and location of the foreign body.
Consider sedation or anesthesia, especially in pediatric patients or for deeply lodged objects.
Be prepared to manage potential complications during the removal process.

What are the steps involved in removing a vaginal foreign body?

The steps for removing a vaginal foreign body typically include:

Position the patient comfortably, usually in the lithotomy position.
Perform a gentle examination to locate and assess the foreign body.
Use appropriate instruments such as forceps or a speculum to visualize and grasp the object.
Carefully remove the object, taking care not to cause additional trauma to the vaginal walls.
Conduct a post-removal examination to ensure complete removal and assess for any injuries.
Provide appropriate aftercare instructions and follow-up recommendations.

Potential Complications of Retained Vaginal Foreign Bodies

Retained vaginal foreign bodies can lead to various complications if left untreated. These may include:

Vaginal or pelvic infections
Toxic shock syndrome (particularly with retained tampons)
Fistula formation between the vagina and surrounding organs
Chronic pelvic pain
Urinary tract infections or obstruction
Fertility issues

How can healthcare providers prevent complications from vaginal foreign bodies?

To prevent complications from vaginal foreign bodies, healthcare providers should:

Maintain a high index of suspicion for foreign bodies in patients presenting with vaginal symptoms.
Conduct thorough evaluations, including appropriate imaging studies when necessary.
Promptly remove identified foreign bodies using safe techniques.
Provide patient education on proper use of tampons, menstrual cups, and other insertable devices.
Ensure proper follow-up care and monitoring for potential delayed complications.

Special Considerations for Pediatric Patients

Evaluating and treating vaginal foreign bodies in pediatric patients requires special considerations:

Be aware that vaginal bleeding or persistent discharge despite antimicrobial treatment should raise suspicion of a foreign body.
Consider referral to a pediatric gynecologist for examination under anesthesia if the diagnosis is unclear.
Use age-appropriate communication and examination techniques to minimize trauma and anxiety.
Always consider the possibility of sexual abuse as a cause for foreign bodies in this population.

What is the most appropriate imaging modality for pediatric patients with suspected vaginal foreign bodies?

For pediatric patients, transabdominal ultrasound is generally considered the most appropriate initial imaging modality. It offers several advantages:

No radiation exposure, making it safer for developing bodies
Greater availability in most healthcare settings
Less invasive compared to transvaginal ultrasound
Good sensitivity and specificity, especially for objects larger than 5 mm

If ultrasound results are inconclusive or complications are suspected, other imaging modalities such as MRI may be considered on a case-by-case basis.

Interprofessional Team Strategies for Improved Outcomes

Managing vaginal foreign bodies effectively requires a collaborative approach involving various healthcare professionals. Interprofessional team strategies can significantly improve patient care and outcomes:

Clear communication between emergency department staff, primary care providers, and gynecologists
Involvement of pediatric specialists when dealing with young patients
Collaboration with radiologists for appropriate imaging selection and interpretation
Integration of mental health professionals for patients experiencing psychological distress
Engagement of social workers in cases involving potential abuse or neglect

How can healthcare teams enhance communication with patients regarding vaginal foreign bodies?

To enhance communication with patients regarding vaginal foreign bodies, healthcare teams should:

Use clear, non-judgmental language when discussing the condition and treatment options
Provide age-appropriate explanations, especially for pediatric patients
Ensure privacy and confidentiality during all interactions
Offer emotional support and address any concerns or anxieties the patient may have
Provide written materials or resources for patients to reference after the consultation
Establish a follow-up plan and clearly communicate it to the patient or caregiver

Preventive Measures and Patient Education

Prevention plays a crucial role in reducing the incidence of vaginal foreign bodies. Healthcare providers should focus on patient education to promote safe practices and increase awareness:

Proper use and timely removal of tampons and menstrual cups
Risks associated with inserting non-medical objects into the vagina
Importance of seeking medical attention for persistent vaginal symptoms
Age-appropriate discussions about genital hygiene and safety
Education on the potential complications of retained foreign bodies

What are some effective strategies for educating patients about vaginal health and foreign body prevention?

Effective strategies for patient education on vaginal health and foreign body prevention include:

Providing clear, written instructions on proper use of menstrual products
Using visual aids or models to demonstrate correct insertion and removal techniques
Offering age-appropriate educational materials for different patient groups
Incorporating discussion of vaginal health into routine gynecological check-ups
Utilizing digital platforms or mobile apps to provide easily accessible information
Encouraging open communication between patients and healthcare providers about sexual health and practices

By implementing these strategies, healthcare providers can empower patients to take an active role in their vaginal health and reduce the risk of foreign body-related complications.

Vaginal Foreign Body Evaluation and Treatment – StatPearls

Continuing Education Activity

Vaginal foreign bodies present in female patients of all ages and a wide range of healthcare settings, including the emergency department, primary care office, gynecology office, and urology office. This activity is designed to inform the reader about vaginal foreign body treatment, removal, and management. It discusses both typical and atypical presentations, as well as complications. It also provides information on how to manage removal as well as how to image patients of various ages.

Objectives:

Identify the anatomical structures of the vagina when evaluating for foreign bodies.
Describe the equipment, personnel, preparation, and technique in regards to removing vaginal foreign bodies.
Review the potential complications of vaginal foreign bodies.
Explain interprofessional team strategies for improving care and treatment for vaginal foreign bodies and improve outcomes. Strategies will be reviewed to enhance communication with patients as well as removal strategies.

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Introduction

Vaginal foreign bodies present in female patients of all ages and a wide range of healthcare settings, including the emergency department, primary care office, gynecology office, and urology office. The objects found differ among age groups. Toys, tissue paper, and household objects are the most common in pediatrics. In adult women, considerations include tampons, condoms, menstrual cups, and items used for sexual gratification. Elderly patients are at increased risk for retained medical devices such as pessaries.[1][2] Patient populations such as prisoners and drug traffickers may use the vaginal canal and uterus to hide illicit substances.[3][4] In postpartum patients with recurrent abdominal pain, pelvic abscess, bladder stones, irritable bladder, and retained surgical gauze merit consideration; however, this is an unusual complication due to patient safety initiatives involving the careful counting of surgical gauze and sponges during delivery. [5]

Patients may self-report a foreign body or may present with an array of symptoms, including pelvic pain, vaginal discharge, and vaginal bleeding. There is a broad differential diagnosis for these symptoms, including malignancy, sexually transmitted infections, candidal infections, and pregnancy. The most common presenting symptom in pediatric patients is vaginal bleeding or discharge.[6]

When evaluating a patient who suspects a vaginal foreign body, history should focus on the details surrounding the initial event; this includes timing, the suspected object, and symptoms of the abdomen, pelvis, and genitalia. History taking is imperative in all patient populations. Even in pediatric patients, the majority, 54% in one study, recall the event.[6] It is essential to consider sexual abuse as a cause for foreign bodies, especially in the pediatric population.

Anatomy and Physiology

The vagina is part of the female genitalia between the urethral meatus and anus. It is a muscular canal that serves as a connection between the external genitalia and the uterus. The vaginal opening has protection from the vulva, a structure comprised of the labia majora and labia minora. At the most proximal portion of the vagina is the cervix, a highly vascularized structure that guards the entrance to the uterus.

Indications

Evaluation for foreign bodies in the vaginal canal is necessary when patients present with a self-reported foreign body or complain of pelvic pain, vaginal bleeding, or discharge. It should also be a consideration in patients with urinary and rectal complaints. In pre-pubertal patients with vaginal bleeding or persistent vaginal discharge despite antimicrobial treatment, imaging, and a gynecology referral for examination under anesthesia should be considered by primary care and emergency physicians.[7]

The examination includes a genital exam, which may include a pelvic exam with a speculum. Imaging is an option if the diagnosis is unclear or complications are suspected; this includes X-ray, CT scan, MRI, and ultrasound. The choice of imaging will vary based on presenting symptoms and patient age. Transabdominal ultrasound is the preferred modality in pediatric patients due to the lack of radiation, increased availability, and decreased level of invasiveness when compared to a transvaginal ultrasound. It has an overall sensitivity of 81% and specificity of 53%, which improves when the foreign body is over 5 mm in size. This percentage is significantly better than X-ray, which may only detect 23% of foreign bodies.[1] CT imaging is an option if complications such as fistula or abscess are suspected.

Contraindications

It is imperative to obtain consent before performing a pelvic examination. Examinations should not take place against patient wishes, as this can constitute assault. In pediatric patients or mentally handicapped patients, consent is necessary from their legal guardians. In these patients, an obstetrics and gynecology consult can be considered to perform an exam under sedation if there is a concern for patient distress. The majority of pediatric patients are manageable with same-day surgery.[8]

The clinician should not perform a pelvic exam if there is suspicion of rape or assault if the patient or guardian has any desire to press charges. In this case, defer the pelvic exam to a specialized investigation team, as introducing anything into the vulva or vagina, even sterile lubrication, can interfere with specimen collection. This approach is a critical consideration in the pediatric population if there is any suspicion for physical or sexual abuse.

Equipment

Several modalities are useful for assessment of the presence of a foreign body in the vagina, including a pelvic exam with or without anesthesia, ultrasonography, pelvic radiography, MRI, and vaginoscopy.[1] Many foreign bodies can be removed with forceps under direct visualization, though those in place for an extended period may require surgical intervention by a gynecologist.

Persistent discharge despite antimicrobial treatment should raise suspicion of a foreign body, and evaluation should take place. [7] It should also remain in the differential for pre-pubertal patients with vaginal bleeding despite a negative ultrasound. Additional radiographic imaging, ultrasonographic imaging, or examination under anesthesia may be required to rule out a foreign body.[9]

Extreme cases may require surgical intervention to remove foreign objects due to size, position, location, and other complicating factors. General anesthesia may be used to allow for full muscle relaxation and aid in foreign body removal.

Personnel

Genital evaluation should be performed with a member of the health care team at the bedside to act as a chaperone. This may occur in an outpatient office or in the Emergency Department. It is important to ask the patient if she prefers to have a female chaperone and to consider having at least one female staff member in the room during the examination. This health care team member, if qualified, can also act as an assistant during the pelvic exam by handing equipment to the provider performing the exam.

In pediatric patients, sedation in the operating room may be considered. In these cases, the usual operating staff, including an anesthesiologist and gynecologist, are necessary.

If ultrasonography is used to evaluate for a foreign body, an ultrasound technician may be required to perform a transabdominal or transvaginal ultrasound.

Preparation

For routine examination in adult patients, preparation for pelvic exams includes asking the patient to remove her lower garments and providing a gown and drape. Privacy is necessary during this step, and a chaperone during the exam is paramount. It is vital that the patient feels comfortable and non-threatened. A non-sterile, lubricated speculum is usable in non-pregnant patients, and a reliable light source should be used to enhance visibility. Culture swabs should be readily available at the bedside if vaginal discharge is reported or appreciated on an exam as foreign bodies are a nidus for infection. Forceps can be brought to the bedside to aid in the removal of foreign material.

Complications

Retained vaginal foreign bodies pose risks. Indwelling foreign objects are niduses for infection; pelvic inflammation can result in infertility.[10] Additionally, compression on surrounding tissues can compromise blood flow resulting in necrosis, a complication that can pose its own sequela, including perforation and fistulas.[10][11] Rectovaginal and vesicovaginal fistulas often occur after foreign bodies have been in place for years. These include medically placed devices such as pessaries and fractured ring IUDs in addition to materials placed by patients. These patients may present with atypical symptoms, including frequent urinary tract infections, vesicle stones, vaginal bleeding, and rectal discharge or bleeding.[12][13][14][15]

Ulceration can also occur, especially if caustic objects are present in the vaginal vault, such as batteries.[10] There are also documented cases of vaginal stenosis after the complete embedding of a foreign object the patient has retained for several years. [10] In extreme cases, chronic inflammation of the surrounding tissue induced by retained foreign bodies can cause carcinogenesis as a result of oxidative and nitrative stress.[16]

Toxic shock syndrome (TSS) is associated most commonly with super-absorbent tampons, but the literature also documents it from other vaginal foreign material such as menstrual cups.[17] It occurs in 0.03 to 0.05 per 100000 individuals and has an overall mortality of 8%. Patients present with fever, rash, desquamation, and sepsis.[18] While the foreign material in the vagina does not directly cause TSS, it acts as a cofactor. The development of TSS requires a lack of antibodies to neutralize toxic shock syndrome toxin 1 and the presence of Staphylococcus aureus in the vaginal flora.[19]

Sharp foreign bodies such as needles can migrate to the gastroenterological system, urologic system, and into the deep pelvis. All symptomatic patients with sharp foreign bodies should have a consultation with gynecology. In patients where removal is complicated, a stable needle can be managed conservatively with a close specialist follow-up.[8]

It is important to note that foreign bodies are a potential cause of infection in all ages. Infection should be on the differential, especially in patients with systemic symptoms, including fever and or tachycardia.

Clinical Significance

Retained vaginal foreign bodies are clinically significant, especially considering the risks that they pose. Foreign bodies are a nidus for infection and may also result in ulceration, bleeding, and fistula formation. Care is necessary when evaluating patients believed to have retained vaginal foreign bodies, and these objects require removal to reduce the risk of complications.

Enhancing Healthcare Team Outcomes

Potential vaginal foreign body cases require an interprofessional effort, including the primary clinician, gynecology specialists, and nursing. Examination for vaginal foreign bodies requires questions about topics that may be sensitive to the patient. It is also important to note the personal aspect of a genital exam. Thus, extra steps are necessary for all personnel involved in the patient’s care. The patient should receive a gown and blanket, and the blanket should be used during the exam to cover anatomy that does not need to be exposed. Providers should speak to the patient openly and refrain from judgmental remarks. A welcoming environment between the providers and patients will enhance medical care by minimizing barriers. It is paramount that privacy is offered, including asking the patient if she would like her visitors to leave the room, and that a chaperone is present. A female nurse can fill the chaperone role, and other nursing duties are covered below. Interprofessional cooperation and teamwork are essential to successful outcomes in these cases. [Level 5]

Nursing, Allied Health, and Interprofessional Team Monitoring

In patients who are awake during the examination, nursing staff should assess the patient throughout the exam for comfort. If sedation is used to perform any portion of the exam when evaluating for a foreign vaginal body, a nurse should monitor vital signs until the patient is awake and alert post-sedation.

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Figure

Types of vaginal foreign bodies. Image courtesy S Bhimji MD

References

1.: Yang X, Sun L, Ye J, Li X, Tao R. Ultrasonography in Detection of Vaginal Foreign Bodies in Girls: A Retrospective Study. J Pediatr Adolesc Gynecol. 2017 Dec;30(6):620-625. [PubMed: 28669787]
2.: Anderson J, Paterek E. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Sep 18, 2022. Flea Bites. [PubMed: 31082162]
3.: Abesamis MG, Taki N, Kaplan R. Uterine Body Stuffing Confirmed by Computed Tomography. Clin Pract Cases Emerg Med. 2017 Nov;1(4):365-369. [PMC free article: PMC5965216] [PubMed: 29849377]
4.: Wankhade VK, Chikhalkar BG. Body packing and intra-vaginal body pushing of cocaine: A case report. Leg Med (Tokyo). 2018 Mar;31:10-13. [PubMed: 29232651]
5.: Wu CC, Hsieh ML, Wang TM. Retained vaginal gauze with unusual complication: a case report. Changgeng Yi Xue Za Zhi. 1997 Mar;20(1):62-5. [PubMed: 9178596]
6.: Stricker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J Paediatr Child Health. 2004 Apr;40(4):205-7. [PubMed: 15009550]
7.: Smith YR, Berman DR, Quint EH. Premenarchal vaginal discharge: findings of procedures to rule out foreign bodies. J Pediatr Adolesc Gynecol. 2002 Aug;15(4):227-30. [PubMed: 12459229]
8.: He Y, Zhang W, Sun N, Feng G, Ni X, Song H. Experience of pediatric urogenital tract inserted objects: 10-year single-center study. J Pediatr Urol. 2019 Oct;15(5):554.e1-554.e8. [PubMed: 31301975]
9.: Nayak S, Witchel SF, Sanfilippo JS. Vaginal foreign body: a delayed diagnosis. J Pediatr Adolesc Gynecol. 2014 Dec;27(6):e127-9. [PubMed: 24656699]
10.: Nakib G, Calcaterra V, Pelizzo G. Longstanding Presence of a Vaginal Foreign Body (Battery): Severe Stenosis in a 13-Year-Old Girl. J Pediatr Adolesc Gynecol. 2017 Feb;30(1):e15-e18. [PubMed: 27614288]
11.: Lo TS, Jaili SB, Ibrahim R, Kao CC, Uy-Patrimonio MC. Ureterovaginal fistula: A complication of a vaginal foreign body. Taiwan J Obstet Gynecol. 2018 Feb;57(1):150-152. [PubMed: 29458888]
12.: Powers K, Grigorescu B, Lazarou G, Greston WM, Weber T. Neglected pessary causing a rectovaginal fistula: a case report. J Reprod Med. 2008 Mar;53(3):235-7. [PubMed: 18441734]
13.: Arias BE, Ridgeway B, Barber MD. Complications of neglected vaginal pessaries: case presentation and literature review. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Aug;19(8):1173-8. [PubMed: 18301852]
14.: Andrikopoulou M, Lazarou G. Rare case of neglected pessary presenting with concealed vaginal hemorrhage. Female Pelvic Med Reconstr Surg. 2015 Jan-Feb;21(1):e1-2. [PubMed: 25185620]
15.: Yan D, Shi Z, Wang L, Zhao X. Migration of a fractured ring IUD resulting in vesicovaginal fistula and vaginal calculus. Eur J Contracept Reprod Health Care. 2018 Oct;23(5):387-389. [PubMed: 30324812]
16.: Osman K, Abdellaoui B, Weyl B, Levêque J. [Uterine Carcinosarcoma induced by a vaginal foreign body: a case report and review]. J Gynecol Obstet Biol Reprod (Paris). 2013 Feb;42(1):91-4. [PubMed: 23062745]
17.: Mitchell MA, Bisch S, Arntfield S, Hosseini-Moghaddam SM. A confirmed case of toxic shock syndrome associated with the use of a menstrual cup. Can J Infect Dis Med Microbiol. 2015 Jul-Aug;26(4):218-20. [PMC free article: PMC4556184] [PubMed: 26361491]
18.: Berger S, Kunerl A, Wasmuth S, Tierno P, Wagner K, Brügger J. Menstrual toxic shock syndrome: case report and systematic review of the literature. Lancet Infect Dis. 2019 Sep;19(9):e313-e321. [PubMed: 31151811]
19.: Vostral S. Toxic shock syndrome, tampons and laboratory standard-setting. CMAJ. 2017 May 23;189(20):E726-E728. [PMC free article: PMC5436965] [PubMed: 28536130]

: Disclosure: Jackie Anderson declares no relevant financial relationships with ineligible companies.
: Disclosure: Elizabeth Paterek declares no relevant financial relationships with ineligible companies.