Author Information
Khadkikar R*, Panchbudhe S**, Channawar S***, Chauhan AR****
(* Assistant Professor, ** Assistant Professor, *** Assistant Professor, **** Additional Professor
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Introduction
Case report
The ring pessary was sent for culture and sensitivity which showed no growth of organisms including actinomycetes. Histopathology report of cervical biopsy specimen revealed no malignancy.
Discussion
Khadkikar R*, Panchbudhe S**, Channawar S***, Chauhan AR****
(* Assistant Professor, ** Assistant Professor, *** Assistant Professor, **** Additional Professor
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Abstract
Vaginal foreign body is
quite common in young children but is a rare finding in adults. This is a case
report of a long forgotten vaginal foreign body (ring pessary) accidentally
found more than 30 years after its insertion. An eighty years old
postmenopausal widow presented with foul smelling, and occasionally bloody
discharge from vagina. She had an impacted, encrusted ring pessary which
required anaesthesia for its removal.
Introduction
Vaginal pessaries have
been used to treat pelvic organ prolapse for over two thousand years.
Approximately 20 different pessary types are available; ring, Gelhorn type and
donut pessaries are used most frequently.[1] They are indicated for
the treatment of genital prolapse in elderly women with significant
co-morbidities that preclude major surgical pelvic floor reconstruction, in women
who desire future childbearing or temporary relief of prolapse while waiting
for surgery, during pregnancy and in women who do not desire surgical repair.
When used properly, pessaries are effective in correcting prolapse and
improving the quality of life in older patients.[2] If forgotten and
neglected, they can lead to complications like vesicovaginal and rectovaginal
fistulae (VVF and RVF), fecal impaction, hydronephrosis, urinary infection,
cervical and vaginal carcinoma [3, 4] Vaginal foreign bodies are
common in children; however there are several reported cases of forgotten
vaginal foreign bodies in adults.[5] A high index of suspicion is
required to arrive at the diagnosis.
Case report
An eighty years old
widow, postmenopausal since 30 years, presented to our outpatient department
with history of foul smelling discharge, vaginal bleeding on and off, and
burning and frequency of micturition for one year. There was no other
significant past medical or surgical history. The patient had 9 full term
normal home deliveries without medical assistance; last childbirth was 40 years
ago.
On examination, her
general and abdominal examination was unremarkable. Speculum examination was
difficult and revealed a urethral caruncle of 1cm diameter, a firm to hard
foreign body in the vagina and a mucopurulent and blood stained discharge. The
cervix was unhealthy, with circumoral erosion which bled on touch. Papanicolaou
smear was collected. On vaginal examination, the uterus was anteverted,
atrophic and bilateral fornices were free. The foreign body was embedded in the
mid vagina with encrustations and calcifications on its surface. On digital
probing it was a thick, hard and circular ring pessary. The vaginal walls were
inflamed with multiple ulcerative lesions; on attempting to remove the pessary
these lesions bled and the pessary could not be dislodged. On enquiry, the
patient recollected that a vaginal ring pessary had been inserted 30 years ago
in her village for the reduction of prolapse after her last childbirth.
Thereafter she had not followed up.
Routine blood and urine
investigations were normal. Papanicolaou smear showed cervical intraepithelial
neoplasia (CIN 2). Transperineal ultrasonography and pelvic radiography
revealed a ring shaped foreign body of approximately 4 to 5 cm diameter with
evidence of calcifications over it. We performed removal of pessary and cervical
biopsy with cryocauterization under general anaesthesia. Removal of the pessary
was difficult. Multiple Allis’ forceps had to be used for its extraction. There
was no active bleeding from the site where pessary was embedded and no obvious
vaginal lesions were seen. The vagina was irrigated with povidone iodine and the
patient was given a course of tablet co-Amoxiclav 625 mg twice a day for seven
days.
Fig 1: Forgotten pessary
during removal
Fig 2: Forgotten pessary
after removal
The ring pessary was sent for culture and sensitivity which showed no growth of organisms including actinomycetes. Histopathology report of cervical biopsy specimen revealed no malignancy.
Discussion
Vaginal pessaries are
devices of made of rubber, silicon, clear plastic, or soft plastic with
internal mouldable steel reinforcement that serve to reposition and support
prolapsed genitourinary organs. Removal of the foreign body can be difficult
and traumatic if impacted in the vagina, as it is associated with erosion and
formation of granulation tissue. Impacted pessaries can be removed only under
anaesthesia; vaginal trauma and bleeding are immediate problems if the removal
is forceful. Irrigation with an antiseptic solution and packing with a pad
after removal are recommended. Forgotten or neglected vaginal pessary can
present with postmenopausal bleeding and VVF[6]. Other differentials
like carcinoma of the cervix and vagina should also be kept in mind.
Our unusual case draws
attention to the fact that foul smelling vaginal discharge of prolonged
duration in elderly women should arouse suspicion of a forgotten ring pessary,
especially with a past history of prolapse. These women remain unaware of the
presence of the foreign body in the vagina or have forgotten about its
insertion, hence do not usually seek medical attention. When the pessary is
fitted, the cognitive ability of the patient should be assessed, and if she has
dementia or has a caregiver, it is essential that the caregiver is made aware
of the pessary placement and follow up requirements. Patient education and
careful follow-up are of paramount importance in prevention of such problems.
Similar case of a Gelhorn
pessary neglected for 3 years leading to a large VVF was reported in an 89
years old woman by Arias; it had to be extracted under anaesthesia using
Schuchardt incision to increase exposure.[4] Hanavati presented a
case of rectovaginal fistula developing secondary to a forgotten vaginal
pessary. [7]
To conclude, pessaries
are safe and play an important role in managing pelvic organ prolapse in
selected patients. With regular follow up, the majority of pessary
complications can be avoided.
References
1.
Baber MD, Walters MD, Cundiff GW, PESSRI
Trial group. Responsiveness of the Pelvic Floor Distress Inventory (PFDI) and
Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing vaginal surgery
and pessary treatment for pelvic organ prolapsed. Am J Obstet Gynecol 2006;
194:1492-1498.
2.
Sulak PJ, Kuehl TJ, Shull BL. Vaginal
pessaries and their use in pelvic relaxation.
J Reprod Med 1993; 38:919-923.
3.
Schraub S, Sun XS, Maingon P, Horiot JC
et al. Cervical and vaginal cancer associated with pessary use. Cancer 1992;69:2505-9.
4.
Arias BA, Ridgeway B & Barber MD.
Complications of neglected vaginal pessaries. International Urogynaecology
Journal 2008; 19:1173-78.
5.
Sticker T, Navratil
F, Sennhauser FH. Vaginal foreign bodies. J Paediatric Child
Health 2004; 40:205-7.
6.
Biswas A, Das HS. An unusual foreign body
in the vagina producing vesicovaginal fistula. J Indian Med Assoc
2002;100:257-59.
7. Hanavati, Derham
Hall, Oke, Aston. Forgotten vaginal pessary eroding into the rectum. Annals Royal
College Surgeons of
England 2004; 86:18 -19.
Citation
Khadkikar
R, Panchbudhe S, Channawar S, Chauhan AR. Forgotten Vaginal Ring Pessary JPGO 2014 Volume 1 Number 1 Available from: http://jpgyob.blogspot.in/2014/01/forgotten-vaginal-ring-pessary.html