Vaginal Foreign Body

A vaginal foreign body is any object retained in the vagina. In adult women common objects are retained tampons, condoms, swabs, pessaries and sex toys. In girls they are toilet paper, small toys and beads.

• A retained object causes foul, often blood-stained discharge.
• Prolonged retention leads to ulceration, fistula, and infection.
• Tampon retention can trigger toxic shock syndrome.

Foul-smelling vaginal discharge, intermittent vaginal bleeding, pelvic discomfort and dyspareunia.

• In girls: persistent blood-stained discharge, perineal soreness, recurrent vulvovaginitis that does not settle with treatment.
• Fever, rash, vomiting, diarrhoea and hypotension suggest toxic shock syndrome.
• Differential diagnosis: bacterial vaginosis, trichomoniasis, cervical or vaginal cancer, genital tract tumour, retained products of conception, sexual abuse in children, vaginal fistula.
• Complications: vaginal ulceration, vesicovaginal or rectovaginal fistula, pelvic infection, toxic shock syndrome, vaginal stenosis.

Diagnosis is by examination, with imaging for objects that cannot be seen.

• Speculum examination in adults; vaginal examination and, in girls, examination in the knee-chest position or under sedation or anaesthesia.
• Pelvic and abdominal X-ray for radio-opaque objects (batteries, beads); ultrasound for others.
• High vaginal swab culture; full blood count; blood cultures if febrile.
• Pregnancy test in women of reproductive age.

Remove the object promptly, treat infection and look for complications.

• Supportive: remove the object promptly; irrigate the vagina with warm sterile saline; analgesia; keep the perineum clean and dry.
• Pharmacological: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); child 15 mg/kg 6-hourly (maximum 1 g per dose). Infection with discharge: metronidazole 400 mg oral 8-hourly for 7 days (child 7.5 mg/kg 8-hourly) with amoxicillin-clavulanate 625 mg oral 8-hourly for 5 days (child 15 mg/kg of amoxicillin component 8-hourly, maximum 500 mg per dose). Toxic shock syndrome: IV fluids, flucloxacillin 2 g IV 6-hourly plus clindamycin 600 mg IV 8-hourly until stable, then oral to complete 10 to 14 days. After long retention with ulceration, oestriol 0.1 percent cream 0.5 g intravaginal nightly for 2 to 3 weeks (adult women who are postmenopausal or atrophic). Give tetanus toxoid 0.5 mL IM if the object is contaminated and immunisation is incomplete.
• Procedures: remove under direct vision using forceps; use sedation or anaesthesia in children and for large, sharp or impacted objects. Remove button batteries and magnets urgently because they cause rapid tissue necrosis. Refer for repair of fistula.
• Special groups: in girls consider sexual abuse and arrange safeguarding review; in pregnancy removal is equally urgent and metronidazole is safe.
• Red flags: fever with rash and hypotension, button battery, magnet, sharp object, fistula, urinary or faecal leakage.
• Follow-up: review at 1 to 2 weeks to confirm healing; examine for stenosis at 3 months.