INTRODUCTION

Some objects like tampon, vaginal suppositories, medications and contraceptive devices
are designed for use in a womans vagina. Others are not intended to be inserted and may be placed
there accidentally or intentionally. These are referred to as foreign bodies. These foreign bodies
may be produce symptoms or be asymptomatic for long periods of time. Small objects inserted
into the vagina do not generally cause pain. Unusual objects which are larger than the customary
vaginal diameter or size of the introitus may cause distension pain. Other objects may cause pain
due to sharp and irregular edges and because of associated infections, which might superimpose.1

Foreign bodies may be ingested , inserted into a body cavity or deposited into the body by
a traumatic or iatrogenic injury. Most foreign bodies inserted into a body cavity often causes only
minor mucosal injury, however they may cause obstruction or perforation, leading to hemorrhage,
abscess formation or septicemia.2 Long standing presence of a foreign body in vagina may cause
vesicovaginal fistula and urinary incontinence. It may be complicated by vaginal stenosis or near
complete obstruction.3 Presence of a foreign body within vagina may be remained undetected for
a long time, until menarche, and then vaginal discharge may, and then vaginal discharge will occur
recurring with each menses. Malodorous vaginal discharge in a child may be due to infection,
sexual abuse, congenital malformation, idiopathic vaginitis, vulvar skin disease, vaginal neoplasm
or a foreign body.2

EPIDEMIOLOGY

The prevalence of vaginal foreign bodies in girls under 20 years with gynecological
disorders was found to be 4 %. Foreign bodies are also found in geriatric population most
commonly in the form of forgotten pessary. It is reported that 49% of the girls with vaginal foreign
body had presented with vaginal discharge.4 Intravaginal foreign bodies are reported to be present
in 4 % of girls younger than 13 years of age presenting with genitourinary complaints.2 Stricker et
al reported that 49% of the girls with vaginal foreign body had presented with blood stained vagina
discharge and almost 20 % with abdominal pain.2 In another study, Caprao reported that the
incidence of vaginal foreign bodies among premenarcheal girls with bloody discharge was 10%.
A restrospective chart review performed by Yolanda et al revealed that in the girls who underwent

1
a vaginoscopy under anesthesia, a foreign body was found in 17.6% and in all cases that presented
with bloody or brown discharge.2

ETIOLOGY

Vaginal purulent discharge in children is mainly due to nonspecific enteric bacterial agents
and specific agents such as group A beta-hemolytic streptococcus hemophilus influenzae and
staphylococcus aureus. Lack of protective effects of estrogens in vaginal mucosa is the main
predisposing factor. Persistent or recurrent foul smelling and/or serosanguineous vaginal
discharge, not responsive to medical therapy in most cases, might be caused by a missed vaginal
foreign body.2 Foreign bodies such as a neglected pessary, an aerosol cap, and vesical calculi are
also documented causes.5 Foreign bodies introduced during such as collagen injected
transurethrally and synthetic materials used in urethral sling procedures can also be inciting
agents.5

Common foreign bodies encountered include tampon, pins, button, seeds, or forgotten
pessaries.4 The most common foreign bodies found in vagina of children are wads of toilet paper,
marbles, beads, paper clips, lead pencil, sponge, plastic stopper, and fibrous material from clotting
and carpet, in adolescent and adult women forgotten menses tampons, the breakage of condom
and less commonly unusual objects as the result of sexual experience.2

Figure 1 : Foreign body- shampoo bottle cap6

2
 Figure 2 : Foreign body shampoo bottle cap, different angle6

Figure 3 : Shell of the battery removed from the vagina4

CLINICAL SYMPTOMS AND SIGNS

The most frequent symptoms are vaginal discharge, often bloody, purulent or foul smelling,
pain in the lower abdomen and supra-pubic region, frequency, burning sensation and dysuria.3
Vaginal foreign body can present with diverse symptoms. It should be considered in any young
female patient presenting with recurrent or persistent vaginal discharge. Vaginal discharge may
result from a variety of causes.4 Presence of foreign bodies can also present with scarring, fistula
formation, recurrent Urinary Tract Infections and infertility.4 Recurrent, unremitting, foul smelling
bloody vaginal discharge in woman should alert the clinician to the possibility of retained vaginal
foreign body.4

FURTHER INVESTIGATION

Methods to rule out a vaginal foreign body include a careful history taking and genital
examination, bimanual recto-abdominal palpation, pelvic ultrasound, plain pelvic radiography,
vaginography and MRI.2 Chia Woei Wang and colleagues have noted that continuous flow

3
vaginoscopy can be used to detect an intra vaginal foreign body, which then may be removed
successfully by hysteroscopy. They concluded that hysteroscopy is safe, convenient, effective and
easy to perform even in children.4

Although vaginal examination generally reveals the presence of foreign body; some
imaging techniques may also be helpful. Other methods to rule out a vaginal foreign body include
pelvic ultrasonography, plain pelvic radiography, vaginography and magnetic resonance imaging
(MRI). MRI is regarded as the best technique for evaluation followed by hysteroscopy.4 The use
of MRI has increased the localization of nonmetallic objects missed by ultrasonographic and
radiologic studies.4 CT scan is also effective in making a diagnosis.

Figure 4 : Abdominal X ray showed a foreign body in the pelvis7

Figure 5 : CT Scan image showing the foreign body in the lower uterine segment4

4
 Figure 6 : A plastic cap of eyebrow pencil inserted to vagina2

Figure 7 : Radiograph of pelvis showing foreign body in situ ( marked with an arrow)1

5
 Figure 8 : Plain X ray of a young girl with two stones in situ8

TREATMENT

Management depends on the object identified and any residual pathology at removal.
Whereas certain objects are removed easily without anesthesia, sharp and potentially hazardous
substances require adequate anesthesia and careful removal. Instruments like obstetric forceps and
ventouse has been used to remove certain objects while laparotomy has been necessary for others.
The vagina usually heals well following the removal of the object, provided there are no
complications such as fistulous formation.4 Treatment requires the removal of the foreign material.
Notably, current methods used to remove vaginal foreign body are hysteroscopy and colposcopy
( if the foreign body is beyond the vagina ).4 A start dose of metronidazole may help to restrore
vaginal flora although no clinical trial support this practice.5

6
 Figure 9 : Foreign body being taken out of vagina, held with clamps1

Figure 10 : Foreign body taken out of vagina, still held with clamps1

Figure 11 : Intra-operative image of cystotomy to remove both stones and repair VVF8

7
COMPLICATIONS

The effect of the object varies with its nature and shape. Perforation, abrasion, pressure
necrosis and local vaginitis result in ulceration of the vaginal walls. This can involve neighboring
structures to cause urinary and fecal fistulae. Ascending infection may lead to salpingitis and
peritonitis. Rarely, neglected pessaries can cause severe ulceration of posterior fornix and lateral
vaginal carcinoma.4 Vaginal foreign bodies can lead to malodorous vaginal discharge and vaginal
bleeding. As, such continuous urinary/watery leakage, recurrent cystitis, persistent odor, skin
infection or irritation or perennial dermatitis may be suggestive of associated vesico-vaginal
fistulae (VVF).8

Tabel 1 : Vesico-vaginal fistulas associated with foreign bodies in vagina8

8
 REFERENCES

1. Brig S Chopra. Case Report : A case of Intravaginal Foreign Body. 2010 Vol.66, No 3 (
Accepted : 14.05.10 )
2. Mohammad Esmaeili. Case Report : Foreign Body as a Cause of Vaginal Discharge in
Childhood. Iran J Pediatr Jun 2008, Vol 18 (No 2 ); Pp: 187-190 ( Accessed 25 December
2007)
3. Josephat M Chinawa. Article : Foreign Body in Vagina : An Uncommon Cause of
Vaginitis in Children. Annals of Medical & Health Sciences Research Jan-March 2013; 3
(1) : 102-104 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3634203
4. Sunanda N., Lokeshchandra H.C. A rare case of foreign body in vagina posing a diagnostic
and therapeutic challenge. International Journal of Recent Trends in Science and
Technology July 2014; 11 (3): 415-417 http://www.statperson.com (accessed 27 July
2014)
5. Barbara L. Hoffman et al (2012). Williams Gynecology : Female Pelvic Medicine and
Reconstructive Surgery 2nd Edition. The McGraw-Hill Companies. United States of
America Pg 680
6. Michal Clebiera. Vaginal Foreign Body Mimicking Cervical Cancer in Postmenopausal
woman . Menopause Review; 14(3) 2015
7. Saloua Ammar et all. Intrauterine Foreign Body in a Child. SM J Pediatr surg. 2016; 2(6)
: 1032
8. Manupriya Sharma. Case Report : A vaginal foreign body presenting as vesico-vaginal
fistulae in a pre-pubertal girl: A case report and review of the literature. Herbet Open
Access Journal 2016 Vol 4: Gynecology 2016
;http://www.hoajonline.com/journals/pdf/2052-6210-4-2-pdf
9. Deeba Khanam., Zehra Mohsin. Foreign Body in Vagina Presenting as Chronic Vaginal
Discharge : a Rare Case Report. International Journal of Scientific Research March 2015
Vol 4 : ( No 3).