Author
Information
Parulekar SV.
(Professor and Head of Department of
Obstetrics and Gynecology, Seth GS Medical College and KEM
Hospital , Mumbai , India
Abstract
Polyembolokoilamania
is inserting a foreign body into one body orifice or more.[1] A case
of self-insertion of an iron rod into the vagina which passed through the
urinary bladder into exptraperitoneal pelvic and abdominal tissues is
presented.
Introduction
Polyembolokoilamania
is inserting a foreign body into one body orifice or more.[1] The
vagina is a not uncommon site of insertion of foreign bodies. These may be self
inserted, as for medical treatment, sexual purposes or to achieve a criminal
abortion; or due to psychiatric reasons. These may be inserted by others with a
view to harm the women concerned, as a part of sexual or physical assault or to
achieve a criminal abortion. Clinical presentation of a foreign body in the
vagina can be varied. It can be catastrophic if the foreign body penetrates
into the peritoneal cavity. In such cases, the patient needs treatment by joint
effort of a gynaecologist, surgeon, and psychiatrist. A case of self-insertion
of an iron rod into the vagina which passed through the urinary bladder into
exptraperitoneal pelvic and abdominal tissues is presented.
Case
Report
A
31 years old woman, para 2 living 2 presented with a complaint of involuntary
passage of urine vaginally for 2 days. She gave a history of passing a pointed
iron rod into her own vagina prior to the beginning of urinary incontinence.
She had had mild vaginal bleeding after the insertion, which had stopped
without any treatment. The patient had been deserted by her husband. She knew
she was HIV positive. She had suicidal tendencies and had inserted the rod thinking
it would kill her. There was no history suggestive of an injury to
intraperitoneal structures. On examination, her general condition was fair and
vital parameters were normal. Systemic examination revealed no abnormality. Her
abdomen was soft, with no tenderness, guarding, rigidity, or free fluid.
Peristaltic .sounds were normal Speculum examination showed a normal cervix,
and a puncture mark in the anterior vaginal fornix a little to the right of the
midline. Urine was seen to be leaking from that puncture. The iron rod was not
visible. Bimanual pelvic examination
showed mild tenderness in the anterior fornix, and normal sized uterus in
retroverted position. No foreign body was palpable. A plain radiograph of the
abdomen and pelvis showed a long, rod-shaped metallic foreign body with a
pointed end in the pelvis and lower abdomen on the right side, the pointed end
pointing upwards (figure 1). There was no free gas under the diaphragm, and no
other abnormality. A Foley’s catheter was passed into the urinary bladder and
continuous drainage of the bladder was maintained. Hemogram of the patient
showed mild anemia and normal white blood cell and platelet counts. Plasma
sugar level, renal and liver function test results were normal. Abdominopelvic
ultrasonography showed the rod-shaped foreign body to be within retroperitoneal
soft tissues A cystoscopy was performed. It showed a 2 mm diameter puncture
mark in the lower anterior wall of the bladder and another in the anterior wall
of the bladder on the right side of the midline. There was no foreign body in
the urinary bladder. An exploratory laparotomy was performed. The foreign body
was removed from retroperitoneal tissues, its tip being near the left psoas
major muscle. It was a 10 cm long iron nail with a pointed end but without a
head. The patient made an uneventful recovery. She was put on antiretroviral
therapy. After continuous bladder
drainage for 14 days, the urinary catheter was removed. She did not have any
urinary incontinence subsequently. Psychiatric evaluation of the patient showed
suicidal tendency. She was treated with psychoactive drugs. Counselling was
done about possible harm from insertion of foreign bodies into the vagina. The
patient agreed not to indulge in such behavior again.
Figure
1. Plain radiograph of the abdomen and pelvis, showing the foreign body.
Discussion
Polyembolokoilamania
is inserting a foreign body into one body orifice or more.[1] Insertion
of a foreign body into the vagina by self might be seen in cases of pessaries
prescribed for prolapse of the uterus, tampons for containing menstrual blood,
or hormone releasing rings for contraception.[2] Foreign bodies may
be inserted by women during masturbation, and a part of the foreign body may
accidentally break inside the vagina.[2] A child may insert a small
foreign body into the vagina during play.[3] But that is not very
common. In places where medical termination of a pregnancy is not legal,
vaginal insertion of sticks, catheters, or plant twigs may be done for
achieving a criminal abortion.[4,5] It may be done for smuggling of illicit drug.[6] It may
be a manifestation of a psychiatric condition, such as malingering, factitious
illness, self-injury, or psychosis.[7] Insertion of foreign bodies
like rods, nails, or knives is usually done as sexual or physical violence
against the woman by another person. There are reports of such insertions for
torture.[8]
This
patient inserted a long nail into the vagina probably under extreme stress of
her medical condition, desertion by the husband, and poverty. The insertion
must have been quite forceful, since it passed through the bladder twice and
into soft tissues in front of the urinary bladder. It was fortunate that the
nail did not pass into the peritoneal cavity and injure bowel. It was also
fortunate that the bladder injuries healed with prolonged catheterization, and
a urinary fistula did not develop.
The
presenting complaints can be vaginal discharge, foul odor, bleeding, and pain. There
are features of local with/without systemic infection. If the peritoneal cavity
has not been entered by a sharp and pointed object, its removal is usually
sufficient. Local and systemic antibiotics are required too. If there is
penetration of the bladder, rectum and/or peritoneal cavity, appropriate
treatment by a specialist is warranted. A criminal abortion with an abortion
stick or catheter may present with severe uterine sepsis, peritonitis and
septicaemia. Besides broad spectrum antibiotics, a total abdominal hysterectomy
and peritoneal drainage is often required. Septic shock needs to be managed
appropriately. Based on the underlying cause, the patient often needs
counselling and psychiatric care.[9]
References
1.
Unruh BT, Nejad SH, Stern TW, Stern TA. Insertion of Foreign Bodies (polyembolokoilamania):
Underpinnings and Management Strategies. Prim Care Companion CNS Disord. 2012;
14(1): Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357565/
2.
Jaluvka V., Novak A. Vaginal foreign bodies in women in
postmenopause and in senium. Eur J Obstet
Gynecol Reprod Biol. 1995;61(2):167–169.
3.
Stricker T., Navratil F., Sennhauser F.H. Vaginal foreign
bodies. J Paediatr Child Health.
2004;40(4):205–207.
4.
Singh S, Deidre W.
Estimated levels of Induced Abortion in six latin American Countries. International
Family Planning Perspectives. 1994;20:4-13.
5.
Fonseca W, Misago C, Correia L,
Parente J, Oliveira FC. Determinants
of induced abortion among women admitted to hospitals in the Nordeste region of
Brazil
6.
Benjamin F., Guillaume A.J., Chao L.P., et al. Vaginal
smuggling of illicit drug: a case requiring obstetric forceps for removal of
the drug container. Am J Obstet
Gynecol. 1994;171(5):1385–1387.
7.
Melamed Y., Dalyahu Y., Vaiman R., et al. Foreign objects in the vagina of a mentally ill woman: case
series. Gen Hosp Psychiatry. 2007;29(3):270–272.
8. THE WOMEN. Available at: http://mneumann.tripod.com/chile3a.html
9.
Van Ophoven A, deKernion J. Clinical management of foreign
bodies of the genitourinary tract. J Urol 2000;164:274–87.
Citation