Case Report Vaginal Foreign Body: A Delayed Diagnosis Shweta Nayak MD 1,*, Selma Feldman Witchel MD 2, Joseph S. Sanfilippo MD, MBA 1 1 2
Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh Medical Center, Pittsburgh, PA
a b s t r a c t Background: To describe a case of prolonged vaginal bleeding in a prepubertal girl. Review of medical record and literature search. Case: A 7-year-old female was referred to our pediatric and adolescent gynecologic clinic for evaluation of vaginal bleeding and ovarian cyst on ultrasonography. Her parents denied any history of trauma or sexual abuse. Initial evaluation revealed pre-pubertal luteinizing hormone and follicle stimulating hormone levels, and follow-up ultrasonography revealed normal pre-pubertal pelvic anatomy. However, a skeletal survey, which was obtained to assess for the presence of skeletal fibrous dysplasia, revealed a metal spring in the vagina. The patient ultimately underwent an exam under anesthesia and vaginoscopy with removal of 3 foreign bodies, with subsequent termination of symptoms. Summary and Conclusions: In cases of pre-pubertal vaginal bleeding, the possibility of vaginal foreign body should not be excluded despite normal sonographic imaging. If clinical suspicion for a vaginal foreign body persists, additional imaging modalities or exam under anesthesia should be considered. Key Words: Foreign Body, Premenarchal, Vaginal bleeding Introduction
Vaginal bleeding in childhood, although relatively uncommon, requires prompt evaluation. The differential diagnosis is broad, and requires a thorough history and physical examination to guide the health care provider (Table 1).1 Vaginal foreign bodies comprise a rare cause of persistent vaginal bleeding. However, swift identification is important because neglected foreign bodies may lead to recurrent urinary tract infection, dermatologic abnormalities, perforation, or fistula formation.2e6 Despite these potential complications, vaginal foreign bodies are underreported in the pediatric and adolescent literature. Of cases that have been described, vaginal bleeding and blood stained or foul smelling vaginal discharge are the leading symptoms at presentation, and the leading culprit is toilet tissue.7,8 Sonographic assessment may be limited in the prepubertal patient. Thus, contemplation of other rare causes of vaginal bleeding may hinder the detection of the foreign body. We present a delayed diagnosis of vaginal foreign body. Notably, the institutional review board at our institution does not require approval of case reports, but consent was obtained from the patient’s parents prior to reporting information from her medical record. Case
A 6-year 10-month old Caucasian female was referred to our outpatient pediatric and adolescent clinic for evaluation of vaginal bleeding, ovarian cysts, and concern for The authors indicate no conflicts of interest. * Address correspondence to: Shweta Nayak, MD, 300 Halket Street, Pittsburgh PA, 15203. Phone: (412)641-1600; Fax: (412)641-1077 E-mail address: [email protected] (S. Nayak).
precocious puberty. According to her parents, she had been experiencing daily vaginal bleeding, requiring the use of 3 pads (daily) for approximately 2 weeks. The persistent vaginal bleeding prompted an emergency department (ED) visit at an outside hospital. During this ED visit, pelvic ultrasonography showed a normal pre-pubertal uterus and bilateral 1.2-2.0 cm anechoic areas on the ovaries considered to represent ovarian cysts. She was subsequently referred to our pediatric adolescent specialty clinic for further evaluation. At this visit, her parents vehemently denied any history of abuse, trauma, or insertion of a vaginal foreign body. On examination, she was Tanner stage I for both breast and pubic hair development. -au-lait macules. She had slight vulvar erShe had no cafe ythema with mild ulcerations and a small amount of blood in the vaginal introitus. This initial evaluation included a repeat US and hormone determinations, along with a serum luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol, complete blood count, comprehensive metabolic panel, total testosterone level, dehydroepiandrosterone sulfate, thyroid stimulating hormone, and Free T4 level]. No ovarian cysts were noted on the repeat pelvic ultrasonography. The patient was re-evaluated 4 weeks later. The family was referred to Pediatric Endocrinology several months later due to the persistence of the vaginal bleeding. At this second visit, her parents reported that the patient was experiencing daily vaginal bleeding and that they had been contacted by the patient’s school because the discharge was becoming so malodorous that the school requested that she be home-schooled. On exam, the patient was noted to have Tanner stage I pubertal development. The vaginal mucosa appeared to be pink, shiny, and non-estrogenized, and although no active vaginal bleeding was noted, a spot of dried blood was noted in the patient’s underwear and a
1083-3188/$ - see front matter Ó 2013 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2013.10.006
2
S. Nayak et al. / J Pediatr Adolesc Gynecol xxx (2013) 1e3
Table 1 Etiologies for Vaginal Bleeding Hormonal Infectious
Inflammatory
Trauma Urologic
Neoplasm
Precocious puberty (gonadotropin dependent or independent) Exogenous hormonal intake Infectious vulvovaginitis Sexually transmitted disease (GC, Chlamydia) Non-sexually transmitted disease (Beta hemolytic strep, S. aureus) Autoimmune disease (lichen sclerosus et atrophicus, lichen simplex chronicus) Poor hygiene Chemical irritants (soaps, cosmetics) Foreign body Sexual abuse Urinary tract infection (bacterial, viral parasites) Neoplasm Urethral prolapse Gonadal stromal tumors (Granulosa cell tumor) Benign tumors (polyps, condyloma accuminata)
strong vaginal odor was present. Finally, a skin examination did not reveal any birthmarks, and a review of her growth velocity did not reveal any recent growth spurt(s). Given the persistent nature of her bleeding, a von Willebrand screen, prothrombin time, and partial thromboplastin time were also obtained. Finally, a skeletal survey was obtained to assess for fibrous dysplasia, as the initial differential also included McCune-Albright syndrome. The patient’s FSH (2.4 IU/mL), LH (!0.03 IU/mL) and estradiol (4 pg/mL) were all in the pre-pubertal range, and the remainder of her laboratory evaluation was within normal limits. A repeat pelvic ultrasonography again demonstrated a normal pre-pubertal uterus and ovaries; however, this time without evidence of ovarian cysts. The skeletal survey, however, revealed a “metallic spiral” in the area of the vagina, without evidence of bone abnormalities (Fig. 1). The patient was taken to the operating room, where an exam under anesthesia and vaginoscopy revealed the existence of 3 foreign bodies: a plastic casing, metal spring, and rubber object, which were all thought to have originated from a pen. Initial nasal speculum evaluation revealed the
Fig. 1. Radiographic Image of patient revealing coiled metal object in the area of the vagina..
presence of friable and slightly denuded vaginal mucosa, which was noted to be just distal to the foreign bodies at the time of vaginoscopy; there was no evidence of perforation or fistulization. There was no active bleeding noted at the sites of friable vaginal mucosa; however in situations where bleeding is encountered, we would recommend applying pressure to the site as well as consideration of light monopolar electrocautery. Following the removal of these foreign bodies, all of the patient’s symptoms completely resolved. Her parents report that vaginal bleeding and foulsmelling vaginal discharge have completely resolved. Summary and Conclusions
Vaginal bleeding in the pediatric patient is a very concerning symptom. A thorough clinical evaluation targeted towards the most common causes often yields a definitive diagnosis. Vaginal foreign bodies can be seen in up to 18% of children with vaginal bleeding and discharge and in up to 50% of children with vaginal bleeding alone.9 However, there are other etiologies for vaginal bleeding that should be considered at presentation (Table 1). As children may be unable to provide a an accurate history, the diagnostic approach to rule out a vaginal foreign body can often be complex, and practitioners rely on the subjective history provided by the parents as well as objective studies, including pelvic imaging. Pelvic ultrasonography is usually the first and most useful imaging modality used to evaluate the pediatric pelvis. However, the availability of experienced technicians and radiologists, who are aware of the developmental changes that take place around puberty, is critical for accurate interpretation of the images.10 Nevertheless, noninvasive imaging may not identify every foreign body, and may be equally less helpful in diagnosing carcinoma as the etiology for the vaginal bleeding.9 The ultrasonographic findings of precocious puberty and foreign body vaginal bleeding are both respectively characteristic and dissimilar. In girls with precocious puberty, the uterus may appear stimulated and an increased number of ovarian follicular cysts. A retained foreign body may be seen as an indentation along the posterior bladder wall.10 Accordingly, although expertise in interpreting images may lead to an earlier diagnosis of vaginal foreign body, it must also be large enough to lead to the characteristic sonographic finding. Additionally, most foreign bodies are not radiopaque and may not be seen on radiographs, but if clinical suspicion remains high despite preliminary normal imaging, a second imaging modality, such as X ray or vaginography, can be considered prior to an exam under anesthesia. The role and timing for vaginoscopy is also a critical consideration during the evaluation of pre-pubertal vaginal bleeding. We utilize vaginoscopy for recurrent or persistent vulvovaginitis, even if symptoms initially respond to antibiotic treatment, unexplained vaginal bleeding, history of vaginal trauma, and for the complete evaluation of a mullerian anomaly. We recommend introducing vaginoscopy as a possible diagnostic and therapeutic tool at the onset of presentation, although the timing of this procedure should be tailored to the specific clinical scenario.
S. Nayak et al. / J Pediatr Adolesc Gynecol xxx (2013) 1e3
A comprehensive approach to the child with vaginal bleeding and discharge is necessary for appropriate management.6 Although challenging, a broad differential should be considered and the possibility of foreign body should not be eliminated despite normal preliminary imaging. References 1. Jamieson MA: Vaginal discharge and genital bleeding. In: Sanfilippo JS, Lara-Torre E, Edmond K, et al, editors. Clinical Pediatric and Adolescent Gynecology. London, Informa Healthcare, 2009, pp 140 2. Evans JM, South MM, Karram MM: Vesicovaginal fistula due to remote history of vaginal foreign body. Female Pelvic Med Reconstr Surg 2012; 18:374e5
3
3. Yu TJ: Urinary tract infection with a neglected vaginal foreign body. J Urol 1997; 157:1475 4. Dalela D, Agarwal R, Mishra VK: Giant vaginolith around an unusual foreign bodyean uncommon cause of urinary incontinence in a girl. Br J Urol 1994; 74:673 5. O'Hanlan KA, Westphal LM: First report of a vaginal foreign body perforating into the retroperitoneum. Am J Obstet Gynecol 1995; 173(3 Pt 1):962 6. Shiryazdi SM, Heiranizadeh N, Soltani HR: Rectorrhagia and vaginal discharge caused by a vaginal foreign bodyea case report and review of literature. J Pediatr Adolesc Gynecol 2013; 26:e73 7. Stricker T, Navratil F, Sennhauser FH: Vaginal foreign bodies. J Paediatr Child Health 2004; 40:205 8. Chinawa J, Obu H, Uwaezuoke S: Foreign body in vagina: an uncommon cause of vaginitis in children. Ann Med Health Sci Res 2013; 3:102 9. Striegel AM, Myers JB, Sorensen MD, et al: Vaginal discharge and bleeding in girls younger than 6 years. J Urol 2006; 176(6 Pt 1):2632 10. Garel L, Dubois J, Grignon A, et al: US of the pediatric female pelvis: a clinical perspective. Radiographics 2001; 21:1393
Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh Medical Center, Pittsburgh, PA
a b s t r a c t Background: To describe a case of prolonged vaginal bleeding in a prepubertal girl. Review of medical record and literature search. Case: A 7-year-old female was referred to our pediatric and adolescent gynecologic clinic for evaluation of vaginal bleeding and ovarian cyst on ultrasonography. Her parents denied any history of trauma or sexual abuse. Initial evaluation revealed pre-pubertal luteinizing hormone and follicle stimulating hormone levels, and follow-up ultrasonography revealed normal pre-pubertal pelvic anatomy. However, a skeletal survey, which was obtained to assess for the presence of skeletal fibrous dysplasia, revealed a metal spring in the vagina. The patient ultimately underwent an exam under anesthesia and vaginoscopy with removal of 3 foreign bodies, with subsequent termination of symptoms. Summary and Conclusions: In cases of pre-pubertal vaginal bleeding, the possibility of vaginal foreign body should not be excluded despite normal sonographic imaging. If clinical suspicion for a vaginal foreign body persists, additional imaging modalities or exam under anesthesia should be considered. Key Words: Foreign Body, Premenarchal, Vaginal bleeding Introduction
Vaginal bleeding in childhood, although relatively uncommon, requires prompt evaluation. The differential diagnosis is broad, and requires a thorough history and physical examination to guide the health care provider (Table 1).1 Vaginal foreign bodies comprise a rare cause of persistent vaginal bleeding. However, swift identification is important because neglected foreign bodies may lead to recurrent urinary tract infection, dermatologic abnormalities, perforation, or fistula formation.2e6 Despite these potential complications, vaginal foreign bodies are underreported in the pediatric and adolescent literature. Of cases that have been described, vaginal bleeding and blood stained or foul smelling vaginal discharge are the leading symptoms at presentation, and the leading culprit is toilet tissue.7,8 Sonographic assessment may be limited in the prepubertal patient. Thus, contemplation of other rare causes of vaginal bleeding may hinder the detection of the foreign body. We present a delayed diagnosis of vaginal foreign body. Notably, the institutional review board at our institution does not require approval of case reports, but consent was obtained from the patient’s parents prior to reporting information from her medical record. Case
A 6-year 10-month old Caucasian female was referred to our outpatient pediatric and adolescent clinic for evaluation of vaginal bleeding, ovarian cysts, and concern for The authors indicate no conflicts of interest. * Address correspondence to: Shweta Nayak, MD, 300 Halket Street, Pittsburgh PA, 15203. Phone: (412)641-1600; Fax: (412)641-1077 E-mail address: [email protected] (S. Nayak).
precocious puberty. According to her parents, she had been experiencing daily vaginal bleeding, requiring the use of 3 pads (daily) for approximately 2 weeks. The persistent vaginal bleeding prompted an emergency department (ED) visit at an outside hospital. During this ED visit, pelvic ultrasonography showed a normal pre-pubertal uterus and bilateral 1.2-2.0 cm anechoic areas on the ovaries considered to represent ovarian cysts. She was subsequently referred to our pediatric adolescent specialty clinic for further evaluation. At this visit, her parents vehemently denied any history of abuse, trauma, or insertion of a vaginal foreign body. On examination, she was Tanner stage I for both breast and pubic hair development. -au-lait macules. She had slight vulvar erShe had no cafe ythema with mild ulcerations and a small amount of blood in the vaginal introitus. This initial evaluation included a repeat US and hormone determinations, along with a serum luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol, complete blood count, comprehensive metabolic panel, total testosterone level, dehydroepiandrosterone sulfate, thyroid stimulating hormone, and Free T4 level]. No ovarian cysts were noted on the repeat pelvic ultrasonography. The patient was re-evaluated 4 weeks later. The family was referred to Pediatric Endocrinology several months later due to the persistence of the vaginal bleeding. At this second visit, her parents reported that the patient was experiencing daily vaginal bleeding and that they had been contacted by the patient’s school because the discharge was becoming so malodorous that the school requested that she be home-schooled. On exam, the patient was noted to have Tanner stage I pubertal development. The vaginal mucosa appeared to be pink, shiny, and non-estrogenized, and although no active vaginal bleeding was noted, a spot of dried blood was noted in the patient’s underwear and a
1083-3188/$ - see front matter Ó 2013 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2013.10.006
2
S. Nayak et al. / J Pediatr Adolesc Gynecol xxx (2013) 1e3
Table 1 Etiologies for Vaginal Bleeding Hormonal Infectious
Inflammatory
Trauma Urologic
Neoplasm
Precocious puberty (gonadotropin dependent or independent) Exogenous hormonal intake Infectious vulvovaginitis Sexually transmitted disease (GC, Chlamydia) Non-sexually transmitted disease (Beta hemolytic strep, S. aureus) Autoimmune disease (lichen sclerosus et atrophicus, lichen simplex chronicus) Poor hygiene Chemical irritants (soaps, cosmetics) Foreign body Sexual abuse Urinary tract infection (bacterial, viral parasites) Neoplasm Urethral prolapse Gonadal stromal tumors (Granulosa cell tumor) Benign tumors (polyps, condyloma accuminata)
strong vaginal odor was present. Finally, a skin examination did not reveal any birthmarks, and a review of her growth velocity did not reveal any recent growth spurt(s). Given the persistent nature of her bleeding, a von Willebrand screen, prothrombin time, and partial thromboplastin time were also obtained. Finally, a skeletal survey was obtained to assess for fibrous dysplasia, as the initial differential also included McCune-Albright syndrome. The patient’s FSH (2.4 IU/mL), LH (!0.03 IU/mL) and estradiol (4 pg/mL) were all in the pre-pubertal range, and the remainder of her laboratory evaluation was within normal limits. A repeat pelvic ultrasonography again demonstrated a normal pre-pubertal uterus and ovaries; however, this time without evidence of ovarian cysts. The skeletal survey, however, revealed a “metallic spiral” in the area of the vagina, without evidence of bone abnormalities (Fig. 1). The patient was taken to the operating room, where an exam under anesthesia and vaginoscopy revealed the existence of 3 foreign bodies: a plastic casing, metal spring, and rubber object, which were all thought to have originated from a pen. Initial nasal speculum evaluation revealed the
Fig. 1. Radiographic Image of patient revealing coiled metal object in the area of the vagina..
presence of friable and slightly denuded vaginal mucosa, which was noted to be just distal to the foreign bodies at the time of vaginoscopy; there was no evidence of perforation or fistulization. There was no active bleeding noted at the sites of friable vaginal mucosa; however in situations where bleeding is encountered, we would recommend applying pressure to the site as well as consideration of light monopolar electrocautery. Following the removal of these foreign bodies, all of the patient’s symptoms completely resolved. Her parents report that vaginal bleeding and foulsmelling vaginal discharge have completely resolved. Summary and Conclusions
Vaginal bleeding in the pediatric patient is a very concerning symptom. A thorough clinical evaluation targeted towards the most common causes often yields a definitive diagnosis. Vaginal foreign bodies can be seen in up to 18% of children with vaginal bleeding and discharge and in up to 50% of children with vaginal bleeding alone.9 However, there are other etiologies for vaginal bleeding that should be considered at presentation (Table 1). As children may be unable to provide a an accurate history, the diagnostic approach to rule out a vaginal foreign body can often be complex, and practitioners rely on the subjective history provided by the parents as well as objective studies, including pelvic imaging. Pelvic ultrasonography is usually the first and most useful imaging modality used to evaluate the pediatric pelvis. However, the availability of experienced technicians and radiologists, who are aware of the developmental changes that take place around puberty, is critical for accurate interpretation of the images.10 Nevertheless, noninvasive imaging may not identify every foreign body, and may be equally less helpful in diagnosing carcinoma as the etiology for the vaginal bleeding.9 The ultrasonographic findings of precocious puberty and foreign body vaginal bleeding are both respectively characteristic and dissimilar. In girls with precocious puberty, the uterus may appear stimulated and an increased number of ovarian follicular cysts. A retained foreign body may be seen as an indentation along the posterior bladder wall.10 Accordingly, although expertise in interpreting images may lead to an earlier diagnosis of vaginal foreign body, it must also be large enough to lead to the characteristic sonographic finding. Additionally, most foreign bodies are not radiopaque and may not be seen on radiographs, but if clinical suspicion remains high despite preliminary normal imaging, a second imaging modality, such as X ray or vaginography, can be considered prior to an exam under anesthesia. The role and timing for vaginoscopy is also a critical consideration during the evaluation of pre-pubertal vaginal bleeding. We utilize vaginoscopy for recurrent or persistent vulvovaginitis, even if symptoms initially respond to antibiotic treatment, unexplained vaginal bleeding, history of vaginal trauma, and for the complete evaluation of a mullerian anomaly. We recommend introducing vaginoscopy as a possible diagnostic and therapeutic tool at the onset of presentation, although the timing of this procedure should be tailored to the specific clinical scenario.
S. Nayak et al. / J Pediatr Adolesc Gynecol xxx (2013) 1e3
A comprehensive approach to the child with vaginal bleeding and discharge is necessary for appropriate management.6 Although challenging, a broad differential should be considered and the possibility of foreign body should not be eliminated despite normal preliminary imaging. References 1. Jamieson MA: Vaginal discharge and genital bleeding. In: Sanfilippo JS, Lara-Torre E, Edmond K, et al, editors. Clinical Pediatric and Adolescent Gynecology. London, Informa Healthcare, 2009, pp 140 2. Evans JM, South MM, Karram MM: Vesicovaginal fistula due to remote history of vaginal foreign body. Female Pelvic Med Reconstr Surg 2012; 18:374e5
3
3. Yu TJ: Urinary tract infection with a neglected vaginal foreign body. J Urol 1997; 157:1475 4. Dalela D, Agarwal R, Mishra VK: Giant vaginolith around an unusual foreign bodyean uncommon cause of urinary incontinence in a girl. Br J Urol 1994; 74:673 5. O'Hanlan KA, Westphal LM: First report of a vaginal foreign body perforating into the retroperitoneum. Am J Obstet Gynecol 1995; 173(3 Pt 1):962 6. Shiryazdi SM, Heiranizadeh N, Soltani HR: Rectorrhagia and vaginal discharge caused by a vaginal foreign bodyea case report and review of literature. J Pediatr Adolesc Gynecol 2013; 26:e73 7. Stricker T, Navratil F, Sennhauser FH: Vaginal foreign bodies. J Paediatr Child Health 2004; 40:205 8. Chinawa J, Obu H, Uwaezuoke S: Foreign body in vagina: an uncommon cause of vaginitis in children. Ann Med Health Sci Res 2013; 3:102 9. Striegel AM, Myers JB, Sorensen MD, et al: Vaginal discharge and bleeding in girls younger than 6 years. J Urol 2006; 176(6 Pt 1):2632 10. Garel L, Dubois J, Grignon A, et al: US of the pediatric female pelvis: a clinical perspective. Radiographics 2001; 21:1393
