Introduction

Pessaries have been used for centuries in the management of uterine prolapse .Vaginal pessaries still have a role in the management of uterine prolapse, particularly in elderly patients. However, they are known to cause serious complications if proper care is not taken. Although surgery is the definitive treatment for severe uterine prolapse, pessaries can give satisfactory results in women who wish or need to avoid surgery₁.

Vaginal foreign body is a rare entity, particularly when detected 45 years after its insertion. The associated erosion and granulation over the vagina make its detection difficult. A high index of suspicion can help arrive in a diagnosis of such foreign bodies in women's body who present with foul smelling bloody discharge.

Case

An 87-year- old postmenopausal woman presented with foul smelly vaginal discharge and occasional blood-stained discharge per vaginum. She was primarily brought to the hospital for general ill-health and impaired eating. She is para 9 with 6 child deaths. Her eldest offspring is a son of 62 and the last childbirth was 48 years ago. All were home deliveries without medical assistance.

On further enquiries, she reported that few years after the last child birth she had uterine prolapse and a doctor in a rural health camp treated her. She did not remember much and at present she was suffering from dementia, hypertension and mitral regurgitation, triscuspid regurgitation, aortic regurgitation, left ventricular hypertrophy and polyneuropathies.

Per speculum examination revealed an atrophic shortened vagina with a rim of granulation in the mid vagina, mucopurulent and blood stained discharge was seen. There was erosion and granulation in the vagina, which made it difficult to retrieve the ring pessary even under sedation.

On per vaginal examination, an irregular rim of hard structure was felt in the mid vagina. The examining finger could be negotiated through the rim upto the cervix that appeared normal. An ultrasonographic evaluation showed a ring shaped object in the vaginal area without any other abnormality.

Examination under sedation revealed a black-coloured ring pessary under the granulation tissue impacted in the vagina. It was dislodged and removed with difficulty and there was little oozing from the vagina. Vagina was irrigated with povidine-iodine and vagina was packed with a pack soaked in povidine-iodine. The pack was removed after twelve hours and there was no bleeding from the vagina. As she had vaginitis and trauma during removal she was given a course of antibiotics for five days.

Figure 1

Figure 1: A photograph showing the extracted vaginal pessary covered with granulation tissue, pus and blood.

Discussion

Vaginal pessaries are devices of varying composition (rubber, clear plastic, silicone, or soft plastic with internal mouldable steel reinforcement) that serve to reposition and support prolapsed genitourinary organs ₂.

Although forgotten foreign bodies in vagina in adults are rare, there have been several cases of forgotten foreign bodies in vagina in adults ₃,₄,₅,₆ and majority of cases of foreign body are found in children ₇,₈. Toys, metallic glasses, screws, hair sprays, plastic covers and drinking glass etc. have been found to be into the vagina. Serious complications like fistula formation ₅, and bowel obstruction ₆ have been reported with retained foreign body in vagina. There are reported cases of rectovaginal fistula, developing secondary to a forgotten vaginal pessary ₉, ₁₀, ₁₁.

Russell ₁₂ reported seeing patients with complications such as a rectovaginal fistula,vaginal cancer or chronic vaginitis . Other complications are incarceration, ulceration and metaplasia₁₃, intestinal obstruction₁₄,₁₅,₁₆ urosepsis and hydronephrosis₁₇,₁₈,₁₉. Jain et al reported two cases of vaginal cancer associated with pessary use ₂₀.

Removal of the foreign bodies which may be impacted in the vagina and associated with erosion and granulation tissue can be difficult and traumatic. It can be removed only under sedation and vaginal trauma and bleeding can be immediate problems associated with the forceful removal of the foreign bodies from the vagina. Irrigation with an antiseptic solution and packing with a pad can be a solution to these problems. These cases have to be differentiated from local conditions such as carcinoma cervix, vaginal cancers, etc.

This unusual case draws attention to the fact that foul–smelling vaginal discharge in elderly women should arouse suspicion of a foreign body. If somebody gives history of uterine prolapse and foul smelly discharge for long, a suspicion of forgotten ring pessary should be a priority. As these women remain unaware of the presence of a foreign body in the vagina or have forgotten about the insertion of a ring in the vagina, they do not usually seek any medical attention.

Correspondence to

Dr Ganesh Dangal, MBBS, MD (OBS/GYN) Consultant Obstertician and Gynecologist Department of Obstetrics and Gynaecology Kathmandu Model Hospital PO Box 12887 Kathmandu Nepal E-mail gareshma@hotmail.com Phone: 00977-1-5555802