Importance of Doppler ultrasound in vaginal foreign body: case report and review of the literature

Abstract

The aim of this paper is to describe the distinctive ultrasound findings of a case of vaginal bleeding caused by the presence of a foreign body. We present the case of an infant who consulted for vaginal bleeding and foul-smelling discharge. The ultrasound revealed signs of vaginal distension due to heterogeneous-hematic contents and parietal thickening. At Doppler examination, a striking finding of increased vascularization limited to the upper two-thirds of the vaginal wall was found, which was initially interpreted as a sign of local inflammation suggesting the presence of an underlying foreign body. At direct vaginoscopic examination remains of toilet paper in the vaginal fundus were found. The presence of a foreign body in the vagina is an uncommon cause of discharge and vaginal bleeding in pediatrics, therefore, this etiology should be kept in mind when the adequate clinical context arises. Doppler ultrasound represents a first-line complementary method when this entity is suspected.

Introduction

Vaginal foreign bodies represent an uncommon finding in pediatrics, accounting for approximately 4% of consultations due to gynecological symptoms and 10% of the visits due to vaginal discharge and vaginal bleeding in girls under 13 years of age [1–4].

The presence of a foreign body in the vagina induces an inflammatory reaction with consequent foul-smelling discharge and vaginal bleeding. Other symptoms that may present, although less specific, are dysuria and abdominal pain [4].

The gynecological physical examination is of great value to rule out signs of hormonal influence or stigmas of sexual abuse [2]. Imaging methods represent a valuable complement in the detection and localization of the foreign body and/or accompanying local inflammatory signs [1, 3, 5]. In this regard, b-mode ultrasound (US) is considered the first-line modality. Although the distinctive characteristics of the different foreign bodies have been described by this method, we have found no reports in the literature of inflammatory changes secondary to vaginal foreign body in pediatrics by Doppler examination [3–5].

The prompt removal of the foreign body is the definitive treatment to avoid potential complications [3]. Among them, we can find: vaginitis, urinary tract infections, vaginal wall ulcerations, perforation and vesicovaginal/rectovaginal fistula [6].

We present a case of a prepuberal patient that presented vaginal bleeding caused by the presence of remains of toilet paper. The aim of this paper is to describe the distinctive characteristics of the US, emphasizing the color Doppler findings.

Case report

A 7-year-old female patient, with age-appropriate growth and development, and no relevant medical history, was brought to our Institution due to foul-smelling blood-stained vaginal discharge. She presented profuse vaginal bleeding at the time of consultation. After a careful interrogation of both the girl and her family, a history of trauma, topical hormone treatments, masturbation, or introduction of foreign bodies was ruled out. The patient was assessed by the pediatric service, revealing Tanner 1 development at physical examination; signs of local erythema and foul-smelling discharge on genital inspection. Vaginal swabs were taken for culture.

Facing the case of vaginal discharge and bleeding with no apparent cause, a combined transabdominal/transperineal gynecological ultrasound (TA/TP US) was requested. The scans were performed with a XARIO 200 (TOSHIBA) US machine using convex and linear probes (PVU-375BT 1.5–6 MHz, PLU-704BT 3–11 MHz), by two pediatric radiologists with 5- and 15-year experience, respectively. In an effort to obtain an adequate acoustic window, the examination was performed with an hour of urinary retention.

The suprapubic B-mode US showed a child-like uterus with a thin endometrium, with both ovaries and adnexal areas free of pathological images. A noteworthy finding was vaginal parietal thickening with distension and occupation of its upper two-thirds by heterogeneous content, which, at the time, was interpreted as hematic remains (Fig. 1). As a striking finding, the color Doppler ultrasound showed increased vascularization of the vaginal wall at that level (Fig. 2). To complete the examination of the lower genital tract, a transperineal approach was performed. Perineum, urethra, cervix and distal vagina were visualized without pathological findings of note.

Fig. 1.

Suprapubic B-mode ultrasound in longitudinal incidences. Distension of the vaginal cavity is observed, which shows heterogeneous-hematic contents with echoes inside and parietal thickening (white arrows). Tubular child-like uterus (arrowhead in a) with a thin endometrium (almost imperceptible), and both ovaries with multiple microfollicles (longitudinal-Dist A1- and anteroposterior-Dist A2-measurements marked between calipers in b are shown). The volume of both ovaries was obtained (not illustrated), which was expected for age and hormonal development. UB urinary bladder

Fig. 2.

Suprapubic color Doppler ultrasound in transverse (a) and longitudinal (b) incidences. Marked increased vascularization limited to the upper two-thirds of the vaginal wall is observed (black arrows), interpreted as a sign of local inflammation/infectious. UB urinary bladder, R rectum

Given the aforementioned imaging findings and suspecting a vaginal foreign body with associated infectious signs, a direct examination was decided. A vaginoscopy was performed under general anesthesia, where the vaginal wall was found to be edematous, with bleeding areas. A foreign body, that turned up to be toilet paper, was found and removed from the vaginal sac.

The patient evolved favorably, with complete remission of the symptoms and subsequent favorable controls.

Discussion

Vaginal discharge and bleeding represent alarming reasons for consultation in prepubertal girls, with recurrent vulvovaginitis being the most frequent etiology [1, 2, 7]. In its physiopathology, a variety of factors intervene such as: anatomic (hypotrophy of the labia majora and proximity of the vaginal introitus to the anus), hormonal (low estrogenic serological levels with increased vaginal mucosa lability) and hygienic factors. Although it may present as blood-stained discharge, it is described as limited and intermittent; therefore, in our case, the presence of profuse vaginal bleeding associated with unusual Doppler ultrasound findings led us to dismiss such etiology. In the initial diagnostic algorithm, physical examination is mandatory to exclude signs of local trauma, precocious puberty, sexual abuse, vulvo-vestibular masses, urethral prolapse, or the presence of a foreign body [2, 7]. In our case, the presence of a thin, intact hymen without any signs of hormonal influence, and a Tanner 1 development on physical examination excluded, at first, the previously mentioned causes.

During childhood and inherent to their development, children explore their bodies and orifices. Particularly, girls between 4 and 9 years of age tend to introduce small objects in their vagina out of curiosity [3]. While reports mention a wide variety of extravagant items found, the authors agree that the most frequently foreign bodies identified are remains of toilet paper, as consequence of a newly acquired independent hygiene practice. [1, 3, 4, 7]. Beads and small parts of toys follow in order of frequency [3].

Even though the presence of blood-stained foul-smelling discharge is highly suggestive of this etiology, often both the patient and the family do not recall this practice [4]. This masks not only the initial diagnosis, but also the estimation of the elapsed time, which can vary from days to years [3]. In our case, we did not count with any history of an object being placed in the vagina, and the patient presented marked inflammatory/infectious signs associated, so we did not know the time of evolution since the introduction of the foreign body or if it was a repetitive practice. This reinforces the importance of a high index of suspicion by the medical team as well as the value of complementary imaging methods.

TA/TP US is currently recognized as the best imaging method for gynecological evaluation in girls, given its innocuous (non-ionizing method) and non-invasive characteristics. Furthermore, it allows the evaluation of the internal genitalia and its correlation with the degree of hormonal development according to age, by estimating the uterine and ovarian volumes (features of great importance to rule out signs of precocious puberty) [3, 5]. As to the detection of the foreign bodies in the vagina, the US has an acceptable sensitivity, so it should be considered as a first-line imaging method [3, 8]. Yang et al. in their retrospective cohort of 249 patients, have arrived at similar sensitivity–specificity data to those previously described (81 and 53%, respectively), with a detection capacity of 100% when the object measures more than 5 mm. They also remark the importance of a combined TA/TP approach for visualizing foreign bodies located in high and low vaginal segments, respectively [3]. In our case, this combined approach revealed an increased vascularization at Doppler ultrasound of the upper two-thirds of the vaginal wall and the presence of hyperechogenic contents in its cavity.

Many echographic signs, such as indentation of the posterior bladder wall have been widely described [3, 5]. Particularly, remains of toilet paper may be seen as focal lesions or hyperechogenic masses without posterior acoustic shadowing; although these findings may be unreliable with false-positive and false-negative results [3]. In a retrospective analysis of the presented case, we estimate that the presence of air bubbles and hematic contents in the vaginal cavity made it difficult to assess the foreign body by means of the US. However, we have not found previous reports in the literature regarding the unique pattern displayed at Doppler ultrasound examination, which we believe corresponds to the inflammatory process associated, and which could be very useful as an indirect sign of the presence of foreign bodies in prepubescent girls. We believe it is relevant to emphasize these findings and to further analyze them in the future, to avoid unnecessary studies.

Conclusion

We have presented a case report of a 7-year-old patient that consulted for vaginal bleeding and foul-smelling discharge due to the insertion of a foreign body. The US revealed the presence of heterogeneous contents in the vagina, and allowed us to rule out other causes of vaginal bleeding. The Doppler ultrasound showed hypervascularization of the vaginal wall, representing an underlying inflammatory process. Finally, at direct examination, remains of toilet paper were found. Although we must always keep in mind the epidemiology and most frequent diagnosis when dealing with a girl with vaginal bleeding, the possibility of a foreign body with unusual findings on US examination should always be evaluated.

Funding

Not applicable.

Availability of data and materials

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Code availability

Not applicable.

Declarations

Conflict of interest

The authors indicate no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from the parents of the individual included in the study.