Vaginal foreign body extraction by forceps: A case report Kevin R. Emge, DO Chicago, Illinois Cases in which foreign bodies have been inserted into the vagina are uncommon but do occur. The technique and use of obstetric forceps for the extraction of an orange as a vaginal foreign body is described in this case report. Tucker-McLane forceps are the forceps of choice for this technique in this case. (AM J Oasrsr GVNECOL 1992;167:514-5.)
Key words: Obstetric for ceps, vaginal foreign bodies, for eign body extraction Vaginal foreign bodies are not common but are seen in the practice of obstetrics and gynecology. Foreign obj ects may be inserted int o th e vagina as an aid to masturbation , sexual intercou rse, or sexual assault. They may be inserted by th e patient or a sexua l partner. Man y different objects ha ve been used , including bones, tampons, billiard balls, thermometers, swizzle sticks, bottles of all type s, drinking glasses, salt cellars , tele vision tubes, wooden shoetrees, pencils, vibrators and other sexual de vices, and vegeta bles and fruits of all varieties. I The sequelae of intravaginal foreign bod ies includes traumatic lesion s to the vagina, rectum, urethra or bladder; infection ; sten osis; and vesicovaginal, re ctovaginal , or urethrovaginal fistulas. Man y different techniques ha ve been used in foreign bod y extrac tion from the vagina and rectum. Ob stetric forceps were used for extraction of a vaginal foreign body in the case presented here. Case report The patient, a 25-year-old white woman, gravida 4, para 3-0-0-3, presented with a viable intrauterine pregnan cy at 28 weeks 3 days' gestation . At approximately 4 A M on the da y of admission th e patient and her intoxicated husband had been engaging in sexual activity when he placed an orange at the perineum and subsequently in the vagina . Neither the patient nor her husband could remove the orange. Later the same morning the y were seen by the patient's famil y practitioner, who was likewise unable to remove the orange. The ph ysician then contacted the labor and delivery tr iage unit at the hospital fo r referral. On arrival at the hospital the patient was placed on a monitor to evaluate fetal well-being and to rule out an y contractions. Screening ultrasonography revealed a viable fetus in a cepha lic position at 28 weeks' gestation. Also noted in From the Department of Obstetrics and Gynecology, Chicago Osteopathic M edical Center. R eceived f or publication February 4, 1992; accepted March 31,
1992.
R eprint requests: Kevin R. Emge, DO, Chicago Osteopathic Medical Center, 5200 S. Ellis Ave., Chicago, IL 60615. 611138213
514
the longitudinal plane was th e rounded vaginal foreign body. On pelvic examination the perineum was minimally ecchymotic, no abrasions or lacerations were noted, and speculum examination revealed an orange in the proximal vagina. Manual extraction was attempted but was abandoned becau se of discomfort and inability to apply proper traction in the needed plane. Because of the similar size of the orange and a small fetal head at term, obstetric for ceps were considered as a possible extraction method. After signing an informed consent, the patient was taken to the delivery room , placed in a dorsal lithotomy position, prepped, and draped as for a vaginal delivery. The patient was given 50 mg of meperidine hydrochloride by slow intravenous push and a pudendal block of 1% lidocaine for discomfort and to relax the perineum. The bladder was drained with a catheter, as is standard for all for ceps procedures. Standard flat-blade Tucker-McLane forceps were lubricated copio usly with gel and applied to the orange in a fashion similar to a direct occipitoanterior fetal head. Gentle traction was applied, and the orange was extracted without discomfort to the patient. Careful examination of the cervix, vagina, and perineum revealed no abrasions or lacerations. The patient was taken to the recovery room for maternal and fetal monitoring and subsequently discharged home. The orange had a circumference of 25 em and a diam eter of 7.8 em. Comment
Because the patient was multiparous, she had a relatively lax perineum, and the foreign body was round and smooth, similar to a fetal he ad , she was an ideal candidate for this type of foreign body extraction. The Tucker-McLane forceps was selected for the following reason s. First, the shanks of Tucker-McLane forceps are overlapping and thus cause less perineal stretching or tr auma than Simpson forceps . This would be especially important in using this technique in a nulliparous patient. An alternate type might be Elliott forceps. Next, the shanks of the Tucker-McLane forceps are extended, making it easier to reach and apply to a higher, more proximal foreign body. As opposed to standard Simpson or Elliott forceps, the Tucker-
Forceps extraction of vaginal foreign bodies
Volume 167 Number 2
McLane forceps has solid, non fenestrated blades that help protect the vaginal sidewalls and perineum during extraction! As with all forceps procedures, the bladder should be empty and appropriate analgesia should be used. The pudendal block worked well in this case, but alternatives include regional or general anesthesia. General anesthesia may be more appropriate if there is suspicion of trauma and a more extensive repair may be needed, especially if there is extension into the bladder, rectum, or peritoneum. In conclusion, this case represents the use of a common instrument of the obstetrician-gynecologist for use
an uncommon situation. This technique can be added to other techniques for vaginal foreign body extraction. In selected cases it may make extraction easier, with less associated morbidity.
10
REFERENCES 1. Piercy SL, Gregory JG, Freel JH. Bladder perforation caused by Cucumis satius repaired per vagina. Urology 1987 ;30:265-6. 2. O'Grady JP. Instruments and indications. In: Modern instrumental delivery. Baltimore: Williams & Wilkins, 1988:39-41.
Leiomyomatosis peritonealis disseminata treated with a gonadotropin-releasing hormone agonist A case report Holly Ann Hales, BS: C. Matthew Peterson, MD: Kirtly P. Jones, MD: and Jeffrey D. Quinn, MD Salt Lake City, Utah To our knowledge, this is the first report of documented growth regression of leiomyomatosis peritonei while the patient was receiving a gonadotropin-releasing hormone agonist. This further documents the role of gonadal steroids in the growth of this tumor. (AM J Oasrsr GVNECOL 1992;167:515-6.)
Key words: Leiomyomatosis peritonealis disseminata, gonadotropin-releasing hormone, tumor regression Leiomyomatosis peritonealis disseminata is a rare condition in which multiple small nodules consisting of benign smooth muscle are found throughout the abdominopelvic viscera and peritoneum. Only two malignant cases have been reported} This is the first report documenting decreased nodule growth with a gonadotropin-releasing hormone (GnRH) agonist.
Case report A 29-year-old woman, gravida 1, para 0-0-1-0, presented with an 8-year history of intermittent and inFrom the Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Utah Medical Center. Received for publication October 24, 1991; accepted January 27,
1992.
Reprint requests: C. Matthew Peterson, MD, Department of Reproductive Endocrinology, Obstetricsand Gynecology, University of Utah Medical Center, Room 28200, 50 N. Medical Dr., Salt Lake City, UT 84132. 6/1137863
creasing left lower abdominal pain. The pain was colick y in nature and had no notable aggravating or alleviating factors. The patient did not have nausea, vomiting, or abnormal weight loss. She did report previous irregular bleeding and had been taking oral contraceptives since 1981. In 1983 she had a cervical fibroid removed by curettage. Pathologic studies confirmed a pedunculated leiomyoma. Because of persistent abdominal complaints, the patient underwent laparoscopy in 1989, which revealed disseminated peritoneal leiomyomatosis (Fig. 1). Multiple small smooth muscle tumors measuring 0.5 to 2 em in diameter were noted on the ovaries, oviducts, anterior and posterior cul-desac, sigmoid colon, round ligaments, uterus, small intestines, and pelvic side walls. Biopsies showed the tumors to be benign. Because of the known association between estrogen and progression of this disorder, the patient was placed on a regimen of leuprolide acetate (Lupron), a GnRH agonist, 0.5 ml subcutaneously daily to shrink tumor implants by decreasing estrogen production. Lupron 515
Key words: Obstetric for ceps, vaginal foreign bodies, for eign body extraction Vaginal foreign bodies are not common but are seen in the practice of obstetrics and gynecology. Foreign obj ects may be inserted int o th e vagina as an aid to masturbation , sexual intercou rse, or sexual assault. They may be inserted by th e patient or a sexua l partner. Man y different objects ha ve been used , including bones, tampons, billiard balls, thermometers, swizzle sticks, bottles of all type s, drinking glasses, salt cellars , tele vision tubes, wooden shoetrees, pencils, vibrators and other sexual de vices, and vegeta bles and fruits of all varieties. I The sequelae of intravaginal foreign bod ies includes traumatic lesion s to the vagina, rectum, urethra or bladder; infection ; sten osis; and vesicovaginal, re ctovaginal , or urethrovaginal fistulas. Man y different techniques ha ve been used in foreign bod y extrac tion from the vagina and rectum. Ob stetric forceps were used for extraction of a vaginal foreign body in the case presented here. Case report The patient, a 25-year-old white woman, gravida 4, para 3-0-0-3, presented with a viable intrauterine pregnan cy at 28 weeks 3 days' gestation . At approximately 4 A M on the da y of admission th e patient and her intoxicated husband had been engaging in sexual activity when he placed an orange at the perineum and subsequently in the vagina . Neither the patient nor her husband could remove the orange. Later the same morning the y were seen by the patient's famil y practitioner, who was likewise unable to remove the orange. The ph ysician then contacted the labor and delivery tr iage unit at the hospital fo r referral. On arrival at the hospital the patient was placed on a monitor to evaluate fetal well-being and to rule out an y contractions. Screening ultrasonography revealed a viable fetus in a cepha lic position at 28 weeks' gestation. Also noted in From the Department of Obstetrics and Gynecology, Chicago Osteopathic M edical Center. R eceived f or publication February 4, 1992; accepted March 31,
1992.
R eprint requests: Kevin R. Emge, DO, Chicago Osteopathic Medical Center, 5200 S. Ellis Ave., Chicago, IL 60615. 611138213
514
the longitudinal plane was th e rounded vaginal foreign body. On pelvic examination the perineum was minimally ecchymotic, no abrasions or lacerations were noted, and speculum examination revealed an orange in the proximal vagina. Manual extraction was attempted but was abandoned becau se of discomfort and inability to apply proper traction in the needed plane. Because of the similar size of the orange and a small fetal head at term, obstetric for ceps were considered as a possible extraction method. After signing an informed consent, the patient was taken to the delivery room , placed in a dorsal lithotomy position, prepped, and draped as for a vaginal delivery. The patient was given 50 mg of meperidine hydrochloride by slow intravenous push and a pudendal block of 1% lidocaine for discomfort and to relax the perineum. The bladder was drained with a catheter, as is standard for all for ceps procedures. Standard flat-blade Tucker-McLane forceps were lubricated copio usly with gel and applied to the orange in a fashion similar to a direct occipitoanterior fetal head. Gentle traction was applied, and the orange was extracted without discomfort to the patient. Careful examination of the cervix, vagina, and perineum revealed no abrasions or lacerations. The patient was taken to the recovery room for maternal and fetal monitoring and subsequently discharged home. The orange had a circumference of 25 em and a diam eter of 7.8 em. Comment
Because the patient was multiparous, she had a relatively lax perineum, and the foreign body was round and smooth, similar to a fetal he ad , she was an ideal candidate for this type of foreign body extraction. The Tucker-McLane forceps was selected for the following reason s. First, the shanks of Tucker-McLane forceps are overlapping and thus cause less perineal stretching or tr auma than Simpson forceps . This would be especially important in using this technique in a nulliparous patient. An alternate type might be Elliott forceps. Next, the shanks of the Tucker-McLane forceps are extended, making it easier to reach and apply to a higher, more proximal foreign body. As opposed to standard Simpson or Elliott forceps, the Tucker-
Forceps extraction of vaginal foreign bodies
Volume 167 Number 2
McLane forceps has solid, non fenestrated blades that help protect the vaginal sidewalls and perineum during extraction! As with all forceps procedures, the bladder should be empty and appropriate analgesia should be used. The pudendal block worked well in this case, but alternatives include regional or general anesthesia. General anesthesia may be more appropriate if there is suspicion of trauma and a more extensive repair may be needed, especially if there is extension into the bladder, rectum, or peritoneum. In conclusion, this case represents the use of a common instrument of the obstetrician-gynecologist for use
an uncommon situation. This technique can be added to other techniques for vaginal foreign body extraction. In selected cases it may make extraction easier, with less associated morbidity.
10
REFERENCES 1. Piercy SL, Gregory JG, Freel JH. Bladder perforation caused by Cucumis satius repaired per vagina. Urology 1987 ;30:265-6. 2. O'Grady JP. Instruments and indications. In: Modern instrumental delivery. Baltimore: Williams & Wilkins, 1988:39-41.
Leiomyomatosis peritonealis disseminata treated with a gonadotropin-releasing hormone agonist A case report Holly Ann Hales, BS: C. Matthew Peterson, MD: Kirtly P. Jones, MD: and Jeffrey D. Quinn, MD Salt Lake City, Utah To our knowledge, this is the first report of documented growth regression of leiomyomatosis peritonei while the patient was receiving a gonadotropin-releasing hormone agonist. This further documents the role of gonadal steroids in the growth of this tumor. (AM J Oasrsr GVNECOL 1992;167:515-6.)
Key words: Leiomyomatosis peritonealis disseminata, gonadotropin-releasing hormone, tumor regression Leiomyomatosis peritonealis disseminata is a rare condition in which multiple small nodules consisting of benign smooth muscle are found throughout the abdominopelvic viscera and peritoneum. Only two malignant cases have been reported} This is the first report documenting decreased nodule growth with a gonadotropin-releasing hormone (GnRH) agonist.
Case report A 29-year-old woman, gravida 1, para 0-0-1-0, presented with an 8-year history of intermittent and inFrom the Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Utah Medical Center. Received for publication October 24, 1991; accepted January 27,
1992.
Reprint requests: C. Matthew Peterson, MD, Department of Reproductive Endocrinology, Obstetricsand Gynecology, University of Utah Medical Center, Room 28200, 50 N. Medical Dr., Salt Lake City, UT 84132. 6/1137863
creasing left lower abdominal pain. The pain was colick y in nature and had no notable aggravating or alleviating factors. The patient did not have nausea, vomiting, or abnormal weight loss. She did report previous irregular bleeding and had been taking oral contraceptives since 1981. In 1983 she had a cervical fibroid removed by curettage. Pathologic studies confirmed a pedunculated leiomyoma. Because of persistent abdominal complaints, the patient underwent laparoscopy in 1989, which revealed disseminated peritoneal leiomyomatosis (Fig. 1). Multiple small smooth muscle tumors measuring 0.5 to 2 em in diameter were noted on the ovaries, oviducts, anterior and posterior cul-desac, sigmoid colon, round ligaments, uterus, small intestines, and pelvic side walls. Biopsies showed the tumors to be benign. Because of the known association between estrogen and progression of this disorder, the patient was placed on a regimen of leuprolide acetate (Lupron), a GnRH agonist, 0.5 ml subcutaneously daily to shrink tumor implants by decreasing estrogen production. Lupron 515
