Foreign objects of long duration in the adult vagina

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Alternating EMA-EP chemotherapy with etoposide, methotrex-
ate, actinomycin, cyclophosphamide, and vincristine (EMA-CO)
chemotherapy is common for high-risk patients. In patients with
placental site trophoblastic tumours, Newlands preferred EMA-EP
to EMA-CO after a relapse or in refractory states and reported a
95% remission rate with the use of EMA-EP (Newlands 2003).
In conclusion, although combination chemotherapy is the main
treatment regimen used in patients with high-risk GTN, surgical
intervention may occasionally be needed to control haemorrhage.
References
Balagopal PG, Pandy M, Chandramohan K et al. 2003. Unusual
presentation of choriocarcinoma. World Journal of Surgical
Oncology 1:4.
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Correspondence: F. Ghaemmaghami, Department of Gynecology Oncology, 2nd Floor, Vali-e-Asr Hospital, Keshavarz Blvd., Tehran
14194, Iran. Tel: þ98 21 6937766. Fax: þ98 21 6937321. E-mail: valrec2@yahoo.com; ftghaemmagh@yahoo.com
DOI: 10.1080/01443610500307748
Foreign objects of long duration in the adult vagina
E. C. NWOSU, S. RAO, C. IGWEIKE, & H. HAMED
Department of Obstetrics and Gynaecology, Whiston Hospital, Prescot, UK
Introduction
A variety of foreign objects are forgotten, transported or left
accidentally in the adult vagina for long periods of time. Such
objects include tampons, sex toys, bottle caps and occasionally
dangerous substances such as corrosive objects or illicit drugs that
put the lives of the women at risk. When objects are retained in the
vagina for a long time, they invariably give rise to excessive vaginal
discharge. With a good history and the patient’s cooperation, it is
often possible to correctly identify the object before retrieval.
Table I. EMA-EP regimen
Drug Dosage Route
Day 1 Etoposide 100 mg/m
2
i.v.
Actinomycin-D 0.5 mg i.v.
Methotrexate 100 mg/m
2
i.v.
Methotrexate 200 mg/m
2
i.v.
Day 2 Etoposide 100 mg/m
2
i.v.
Actinomycin-D 0.5 mg i.v.
Citrovorum factor 15 mg i.m. or p.o.
Start 4th dose 24 h after Methotrexate
Day 8 Etoposide 100 mg/m
2
i.v.
Cisplatin 60 – 80 mg/m
2
i.v.
Every 7 days: 1, 2, 8, . . . 15, 16, 22
i.v., intravenously; i.m., intramuscularly; p.o., by mouth.
Figure 3. Choriocarcinoma with large bowel metastasis. The
tumour (right upper portion of the picture) and large intestinal
mucosa (left lower portion) are seen in a background of
extravasated red blood cells (6400).
Gynaecology case reports 737

However, in circumstances where cooperation is lacking either due
to the woman’s mental state, discomfort or illicit activity, this is not
always possible and various radiological techniques have been
employed with varying degrees of success. We report two case
reports of foreign bodies in the adult vagina, and discuss their
management, with a literature review.
Case 1
A 44-year-old patient was admitted through the Accident and
Emergency Department with a 2 week history of offensive vaginal
discharge associated with fever and vomiting. She gave a history of
having used batteries for sexual stimulation two months earlier,
during which one battery had accidentally been retained in the
vagina. Her effort to retrieve the battery was unsuccessful. Two
months on, she had neither felt nor seen the battery fall out. She
had no associated urinary or bowel symptoms.
She was unmarried, had no children and lived on her own. She
had mitral valve stenosis, irritable bowel and diverticular disease.
On examination she was flushed, pale, pyrexial (38.5C), pulse
(96 bpm) and had a blood pressure of 130/80 mmHg. The
abdomen was distended and moderately tender. Vaginal examina-
tion revealed large amounts of offensive greenish discharge. A full
bacteriological screen was done. The inferior aspect of a metal
object was noted stuck in the posterior fornix. Slight movement of
the object was associated with discomfort and bleeding. An
attempt at removal caused severe discomfort and brisk bleeding.
An erect abdominal X-ray (Figure 1) showed the presence of a
battery in the vagina. She was commenced on intravenous
antibiotics and metronidazole and taken to theatre.
At surgery, an AA size Duracell battery was removed without
difficulty from the posterior fornix, where it was found to be
embedded, exposing a raw area of 3 6 3 6 4 cm. The rawness was
limited to the skin with no evidence of fistula. No active bleeding
was observed. The general ooze responded to pressure. The battery
surface was corroded and had leaked. She was discharged after 48 h
and seen for review 8 weeks later, when all was well. She had no
complaints, declined vaginal examination and was discharged.
Case 2
A 34-year-old Para 1 þ 2 was admitted at 32 weeks’ gestation as an
emergency on labour ward with a 7 day history of increasing lower
abdominal discomfort associated with having accidentally sat on a
strange object in a public toilet. She felt the object push completely
into her vagina as she sat down. She had increased non-offensive
whitish discharge but there was no associated pain or vaginal
bleeding and she had not noticed any change in fetal activity.
There was no significant medical or surgical history and the
pregnancy had been uncomplicated.
On examination she looked well and was not unduly apprehen-
sive. Her pulse was 80 bpm, temperature 36.88C and blood
pressure of 120/80 mmHg. Her abdomen was soft and the uterine
size was consistent with the gestation. The fetal presentation was
cephalic and the heartbeat was heard with a sonicaid. The
cardiotocographic tracing was normal. She declined vaginal and
speculum examination. A hard object was felt in the vagina on a
gentle digital examination. An abdominal ultrasound though
suboptimal because of discomfort revealed a hard shaped object
in the vagina. She was taken to theatre where a deodorant stick
(Figure 2) was removed without difficulty. Her recovery from
anaesthesia was uneventful and she was discharged after 24 h. The
pregnancy progressed uneventfully to term, resulting in a
spontaneous labour and vaginal delivery of a healthy male infant.
Discussion
An extraordinary array of foreign bodies has been recovered from
the adult vagina after a long duration (Ahmad 2002; Meniru et al.
1996; O’Hanlon and Westphal 1995). The majority of objects
found include contraceptive devices, forgotten tampons, sur-
gical instruments (often forgotten) and sexual aids retained
Figure 1. X-ray showing the presence of a battery in the vagina.
Figure 2. Deodorant stick removed from the vagina.
738 Gynaecology case reports

inadvertently (Benjamin et al. 1994; Emge 1993; Kurzel et al.
1981; Oram and Beck 1981).
Several reasons have been given why these objects are found.
Medical devices inserted include pessaries for treatment of
uterovaginal prolapse but forgotten surgical instruments such as
gauze swabs have been documented. Because of the unique
qualities of the vagina and its expansive ability it has been used for
transportation of illicit drugs and recognised as such by law
enforcement officials. In today’s contemporary society where sex
toys are freely available for personal sexual gratification, it is not
uncommon to find varieties of such objects used and forgotten or
retained in the vagina (Meniru et al. 1996). Whereas what is found
in women with mental illness varies from the simple to the bizarre,
forgotten pessaries and contraceptive devices tend to be more
common in older women. In women of menstrual age, forgotten
tampons and sex toys predominate, while drug carriage is more
common in international travellers.
The presence of a foreign body in the vagina stimulates the
vaginal mucosa to produce more secretions giving rise to increased
vaginal discharge, which is the most common symptom. Discharge
often becomes smelly, blood stained and infected in the course of
time. Because of the high absorptive properties of the vagina, illicit
drugs inappropriately wrapped can get absorbed with terrible
consequence as in the ‘body packers’ syndrome (Benjamin et al.
1994; McCarron and Wood 1983; Pelosi et al. 1992). Various
complications like trauma, migration into the bladder, perforation
with peritonitis, vaginal and pelvic adhesions, corrosion and fistula
formation have been documented (Benjamin et al. 1994;
McCarron and Wood 1983; Meniru et al. 1996; O’Hanlon and
Westphal 1995; Pelosi et al. 1992). Diagnosis is based on good
history as shown in both cases. A full bacteriological screen is
important to identify any infecting organisms. When illicit
substances are suspected, it is vital to send samples for biochemical
and drug analysis. Because vaginal examination can be difficult,
various radiological assessments such as an X-ray of the pelvis in
the first case and ultrasound in the second may be necessary to
identify foreign objects prior to surgery (Caspi et al. 1994). If non-
compliance or pregnancy make X-rays inappropriate, new devel-
opments in imaging with 3D multiplanar Display, RealTime 4D
ultrasound inco-operating 3D Surface Rendering technologies can
now correctly identify the object before surgery is undertaken
especially when toxic objects are suspected and safety is
paramount.
Management depends on the object identified and any residual
pathology at removal. Whereas certain objects removed are easily
without anaesthesia, sharp and potentially hazardous substances as
in Case 1 require adequate anaesthesia for careful removal and
assessment. Instruments like the obstetric forceps and ventouse
have been used to remove certain objects, while laparotomy has
been necessary in others (Emge 1993; O’Hanlon and Westphal
1995). The vagina usually heals well following the removal of
objects, provided there are no complications such as fistulous
formation.
References
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Correspondence: E. C. Nwosu, Obstetrics & Gynaecology Unit, Whiston Hospital, Warrington Rd, Prescot, L35 5DR, UK. Tel: 0151 430
1495. Fax: 0151 430 1335. E-mail: ezechinwosu@hotmail.com
DOI: 10.1080/01443610500307813
Gynaecology case reports 739