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CASE REPORT
Year : 2019  |  Volume : 12  |  Issue : 2  |  Page : 157-159  

Vaginal foreign body in a child: Sexual abuse or sibling prank?


1 Department of Paediatric Surgery, Kota Medical College, Kota, Rajasthan, India
2 Department of Obstetrics and Gynaecology, Kota Medical College, Kota, Rajasthan, India

Date of Submission11-Mar-2018
Date of Acceptance05-Jul-2018
Date of Web Publication25-Mar-2019

Correspondence Address:
Rahul Gupta
Department of Paediatric Surgery, Kota Medical College, Kota, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_46_18

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  Abstract 


Vaginal foreign body is a rare condition. We present a 6-year-old girl who had dysuria and itching in the perineum; examination revealed a vaginal foreign body which was a broken safety pin. Radiographs after its removal revealed a pin of the safety pin left in the vagina which was later removed under anesthesia. A high index of suspicion for a vaginal foreign body should be present while evaluating a child with genitourinary complaints. Vaginal foreign body in children may be an indicator of possible sexual abuse; although in the present case, it was a prank by her elder sibling. Importance of postprocedural radiographs has been emphasized after removal as multiple/broken pieces may be present, which may not have been visualized initially. Evaluation for concurrent sexually transmitted diseases is paramount if sexual abuse is suspected.

Keywords: Child, prank, safety pin, sexual abuse, vaginal foreign body


How to cite this article:
Gupta R, Patidar BL. Vaginal foreign body in a child: Sexual abuse or sibling prank?. Med J DY Patil Vidyapeeth 2019;12:157-9

How to cite this URL:
Gupta R, Patidar BL. Vaginal foreign body in a child: Sexual abuse or sibling prank?. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Apr 18];12:157-9. Available from: http://www.mjdrdypv.org/text.asp?2019/12/2/157/254771




  Introduction Top


Vaginal foreign body is a rare entity, particularly in the pediatric population.[1],[2] Vaginal foreign body is more common in mentally retarded and young children.[1],[2] The patient may present with vaginal discharge or genitourinary symptoms, and the condition may remain undiagnosed for years.[3],[4] We present a 6-year-old girl who presented with complaints of dysuria and itching in the perineum and on examination was found to have a vaginal foreign body. Furthermore, a brief review of pertinent literature is endeavored.


  Case Report Top


A 6-year-old girl who lived with her parents presented with complaints of dysuria and itching in the perineum for few days. There was no history of lower abdominal pain or fever. There was the absence of any preceding sexual abuse or family discord.

Examination revealed an anxious child with poor understanding. On perineal examination and on separating her labia, no vaginal discharge was present. There was the absence of any excoriation on the vaginal wall (no obvious sign of sexual abuse), but hymen was not intact. A suspicious object (a foreign body) in the lower vagina was seen. The foreign body was grasped with curved artery forceps and gently removed; it was a broken safety pin [Figure 1]. Vagina was carefully inspected for the presence of other foreign bodies. After the procedure, abdominopelvic radiographs (both anteroposterior and lateral) were performed to evaluate for any other associated foreign bodies. It revealed radiopaque foreign body in the vagina [Figure 2]. The patient was planned for examination under anesthesia. After preparation, vaginoscopy was performed which revealed a broken pin near the posterior vaginal fornix. A broken pin of the safety pin [Figure 2] was removed from the vagina with the help of long artery forceps. Vaginal swabs were taken for culture sensitivity. Symptoms resolved after removal of the foreign body followed by single irrigation with povidone-iodine. Oral antibiotics were given for 7 days to prevent infection owing to lack of the protective effects of estrogen on vaginal mucosa. The vaginal swab culture reports were normal; the patient was also evaluated for any sexually transmitted infections such as syphilis, hepatitis, and HIV.
Figure 1: Photograph (a) after separating the labia showing a foreign body in the lower vagina; (b) removed broken safety pin

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Figure 2: Abdominopelvic radiographs (a), anteroposterior and (b) lateral showing radiopaque foreign body in the vagina, and photograph showing (c) broken pin of the safety pin (specimen)

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On enquiring confidentially, the child revealed that while playing, her elder sister had introduced the safety pin in her vagina. An enquiry of the family members indulging in unnatural sexual behavior was also conducted. Consultation of gynecologist was sought in view of hymen not being intact; any sexual offence looked unlikely. A psychiatrist opinion was also sought for the patient and her 10-year-old elder sister who had inserted the foreign body.


  Discussion Top


Vaginal foreign body may result from ignorance, accident, malice, attempts at sexual stimulation, mental retardation, or psychotic tendencies.[2] A variety of foreign bodies may be retrieved from the vagina such as buttons, grains, hairpins, pencils, small jam jars, toys, sweets, pieces of toilet paper, and safety pins (as seen in the index case).[1],[2],[3],[4] Multiple foreign bodies may also be present.[2],[5]

A mean age of 6.3 years was seen in a large series with vaginal foreign bodies in prepubertal girls.[5] The age usually ranges from 2 to 10 years in pediatric patients.[4] The presentation is usually with recurrent, bloodstained, and foul-smelling discharge that may be associated with vulvar and vaginal inflammation up to 50% of the patients.[3],[4] Spotting, vaginal bleeding, or bloody discharge in a prepubescent girl are the most observable symptom. The child may be symptomatic for years and purulent discharge may be resistant to antibiotic therapy.[4] Symptoms may include lower abdomen pain or in the suprapubic region, frequency, burning sensation, or dysuria (as seen in our case).[6],[7] Complications such as vaginal perforation, fistulae formation, and systemic infection have also been reported.[6] Ascending infection may lead to salpingitis, pelvic inflammatory disease, and peritonitis.[6] A high index of suspicion is required in diagnosing small-sized foreign body in young children. A carefully obtained history may sometimes suggest the diagnosis, but a detailed examination of the perineum is important in an young child with urinary or vulvovaginal symptoms as the child may not give the relevant information.[4]

In children, vaginal foreign body sometimes may be incidentally diagnosed on a plain radiograph, ultrasound, or other investigations done for some other reason. Transperineal ultrasonography along with transabdominal ultrasonography has been shown to be very helpful in diagnosing vaginal foreign bodies, especially when the size is larger than 5 mm. Vaginal foreign body is hyperechoic as compared to adjacent tissues and often with characteristic echo patterns. It has been recommended for the initial evaluation of suspected vaginal foreign body cases. It has sensitivity and specificity of 81% and 53%, respectively.[8] Pelvic radiographs (both anteroposterior and lateral) detect metallic and radiopaque foreign bodies. Pelvic radiography is less sensitive (24%) but highly specific (91%) for vaginal foreign body.[8] Magnetic resonance imaging is the best investigative modality for evaluating vaginal foreign bodies, but normal report does not rule out its possibility.[3],[9] It is radiation free in contrast to computerized tomography. Finally, direct visualization of vagina under anesthesia is confirmatory.[3]

Once diagnosed, the removal of foreign body is the definitive treatment. In the first attempt, we could do it as the outpatient procedure, because the girl was very cooperative and the foreign body was in the lower portion of vagina. The removal of a vaginal foreign body in outdoor clinic is difficult. The procedure almost always requires anesthesia, as was done for the remaining foreign body in our case.[3]

A foreign body in the lower portion of vagina or near the introitus may be visible only by gently separating the labia and may be removed easily with the help of an artery forceps. However, proximally situated, pointed, sharp, or embedded foreign body, particularly in the posterior fornix of the vagina may need an examination under anesthesia. Vaginoscopy or endoscopic removal (as done in the index case) is the best method for removal of foreign body vagina.[3]

Furthermore, nonpointed, hard foreign bodies, for example, button battery embedded in the posterior fornix of vagina can be felt by the examining finger inserted into the rectum, and then, by gently maneuvering the finger in its assisted removal (Personal experience, Rahul Gupta). Importance of postprocedural radiographs has also been emphasized after removing the vaginal foreign body (as outpatient procedure) because multiple/broken pieces may be present, which may not have been visualized initially.

The foreign body may be self-inserted by the girl or other children while playing.[3],[4] A psychiatrist opinion for underlying psychological assessment, emotional, and behavioral problem is important. In the present case, it was prank by her elder sibling who had introduced the safety pin in her vagina. Evaluation for possible sexual abuse is paramount as two-third of these girls with vaginal foreign body may be sexually abused.[5] Consultation with child sexual abuse experts has been recommended by experts.[10] Evaluation for concurrent sexually transmitted diseases should also be done for those with sexual abuse as one-fourth of these cases may be positive.[5]


  Conclusion Top


The possibility of vaginal foreign body should be kept in mind while evaluating a child with genitourinary complaints such as dysuria and itching (as seen in the present case) or with bloody vaginal discharge. Thorough perineal examination, especially in children is paramount.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Halder P, Mandal KC, Mishra L, Debnath B. Spectrum of vaginal foreign body in children: A report of two cases. Indian J Paediatr Dermatol 2017;18:220-2.  Back to cited text no. 1
  [Full text]  
2.
Padmavathy L, Ethirajan N, Rao LL. Foreign body in the vagina of a 3(1/2)-year-old child: Sexual abuse or a childish prank? Indian J Dermatol Venereol Leprol 2004;70:118-9.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Chaurasia A, Gupta V, Mishra A. Vaginal foreign body in a 6 year old girl: A game for the child but a challenge for the gynaecologist. Int J Reprod Contracept Obstet Gynecol 2015;4:518-20.  Back to cited text no. 3
    
4.
Stricker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J Paediatr Child Health 2004;40:205-7.  Back to cited text no. 4
    
5.
Herman-Giddens ME. Vaginal foreign bodies and child sexual abuse. Arch Pediatr Adolesc Med 1994;148:195-200.  Back to cited text no. 5
    
6.
Chinawa J, Obu H, Uwaezuoke S. Foreign body in vagina: An uncommon cause of vaginitis in children. Ann Med Health Sci Res 2013;3:102-4.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Dahiya P, Sangwan K, Khosla A, Seth N. Foreign body in vagina – An uncommon cause of vaginitis in children. Indian J Pediatr 1999;66:466-7.  Back to cited text no. 7
    
8.
Yang X, Sun L, Ye J, Li X, Tao R. Ultrasonography in detection of vaginal foreign bodies in girls: A retrospective study. J Pediatr Adolesc Gynecol 2017;30:620-5.  Back to cited text no. 8
    
9.
Kihara M, Sato N, Kimura H, Kamiyama M, Sekiya S, Takano H, et al. Magnetic resonance imaging in the evaluation of vaginal foreign bodies in a young girl. Arch Gynecol Obstet 2001;265:221-2.  Back to cited text no. 9
    
10.
Closson FT, Lichenstein R. Vaginal foreign bodies and child sexual abuse: An important consideration. West J Emerg Med 2013;14:437-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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