Vaginal foreign bodies
A retained object in the vagina, most often a forgotten tampon in a reproductive-age patient or a small toy or paper wad in a prepubertal child, presents with malodorous purulent discharge and can seed staphylococcal toxic shock syndrome; management is removal plus, if the TSS triad is present, vancomycin and clindamycin.
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What this article covers
- Overview
Definition: an object retained within the vagina beyond its intended or expected duration, most commonly a forgotten tampon in a reproductive-age patient or a small toy, paper wad, or bead in a prepubertal child.
- Epidemiology
Foreign objects are the most common cause of pediatric vaginal discharge, more common than infectious or noninfectious vulvovaginitis in prepubertal girls.
- Risk factors
Prolonged tampon use beyond the recommended interval, the classic antecedent of menstrual TSS.
- Pathophysiology
Local mucosal irritation and secondary bacterial overgrowth from the retained object produce the malodorous, purulent discharge that is the presenting complaint.
- Clinical features
Malodorous, purulent, often blood-tinged or brown vaginal discharge is the hallmark presenting symptom in both children and adults with a retained object.
- Differential diagnosis
Staphylococcal toxic shock syndrome as the presenting event rather than a complication already searched for: a history of tampon use, not a visible object, is the discriminator that should redirect…
- Diagnosis
This is a clinical diagnosis confirmed on direct visualization: a foreign body is confirmed by speculum or vaginal exam revealing the retained object, malodorous discharge, and vaginal wall erythema…
- Management
First, remove the foreign body. In an adult, this is usually achieved with ring forceps at speculum exam; in a child, gentle vaginal irrigation with warm saline via a small catheter, or removal under…
- Complications
Staphylococcal toxic shock syndrome, with a mortality rate of 3 to 6 percent; death results from cardiac arrhythmias, cardiomyopathy, ARDS-related respiratory failure, or disseminated intravascular coagulation.
- Prognosis
Excellent with prompt removal and, when present, aggressive TSS management: most patients recover fully once the object is removed and, if TSS has developed, once source control and antibiotics are started.
- Prevention
Counsel tampon users to change tampons every 4 to 8 hours and to avoid leaving any single tampon in place overnight beyond 8 hours, the interval cited to reduce menstrual TSS risk.
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Related articles
- Staphylococcal toxic shock syndrome
Staphylococcal toxic shock syndrome is a multisystem, toxin-mediated illness caused by TSST-1-producing Staphylococcus aureus acting as a superantigen, classically linked to prolonged tampon use, nasal packing, or a focal staphylococcal infection, diagnosed by a clinical case definition of fever, hypotension, diffuse desquamating rash, and involvement of three or more organ systems, and treated with source control plus antistaphylococcal antibiotics including clindamycin.
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Pelvic inflammatory disease is an ascending polymicrobial infection of the upper female genital tract, most often caused by Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium, diagnosed clinically on uterine, adnexal, or cervical motion tenderness. Most women are treated as outpatients with a single dose of ceftriaxone plus 14 days of doxycycline, while parenteral cefotetan or cefoxitin plus doxycycline, or clindamycin plus gentamicin, is reserved for hospitalized patients, with tubo-ovarian abscess and infertility among the major complications of delayed treatment.
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Acute cervicitis is inflammation of the uterine cervix diagnosed by visualized mucopurulent endocervical discharge or a friable os that bleeds with a swab, most often caused by Neisseria gonorrhoeae or Chlamydia trachomatis, treated empirically at the same visit while nucleic acid amplification testing is pending.
- Labial adhesions
Labial adhesions are agglutination of the labia minora along the midline in a hypoestrogenic prepubertal girl, usually an incidental finding that resolves with estrogenization at puberty but occasionally causing urinary pooling or recurrent infection that warrants topical therapy.
- Vulvar lichen sclerosus
Vulvar lichen sclerosus is a chronic inflammatory dermatosis causing porcelain-white atrophic plaques, itching, and scarring of the vulva, confirmed by biopsy and treated with an ultrapotent topical corticosteroid to relieve symptoms and reduce the lifelong risk of vulvar squamous cell carcinoma.
- Vaginal cancer
Primary vaginal cancer is a rare gynecologic malignancy, usually squamous cell carcinoma linked to HPV, that must be distinguished from the far more common metastatic or direct extension of cervical, endometrial, or vulvar cancer into the vagina. Diagnosis rests on biopsy of a visualized lesion with clinical FIGO staging, and treatment is predominantly radiation with concurrent platinum-based chemosensitization.