A Zebra in the Emergency Department
Many cases of vaginal foreign body are unusual and often difficult to detect.
This article has been edited from the original to reflect the correction of the misrepresentation of the physician assistant job title. The Clinical Advisor sincerely regrets this error.
Vaginal foreign body (VFB) is a diagnosis that is often encountered in the emergency department (ED), yet it may be easily misdiagnosed. Several dynamics are present in the ED setting that can contribute to misdiagnosis and delayed treatment. Each year in the United States, there are countless ED visits that result in the diagnosis of VFB; however, the number of cases that were initially missed or misdiagnosed remains unknown. Serious consequences of delayed diagnosis and treatment can include infection, vaginal abrasion, ulceration, perforation, and fistula.1 Many cases are not straightforward and can become zebras in the ED setting: unusual cases that are difficult to detect.
In the ED setting, the presentation of VFB can be considered a zebra by many clinicians, especially in light of the plethora of more common diagnoses such as candidiasis, bacterial vaginosis, and trichomoniasis.2 Forgotten tampons are one VFB cited frequently in the majority of cases.3
Despite the known educational maxim that touts that clinicians should “focus on the horses — the most common presentations of medical problems — and not the zebras”,4 in the case of VFB, clinicians might fare better by considering the zebra cases and by placing VFB on the top of their differential diagnosis list, especially for patients who return to the ED for the same complaint (also referred to as “bounce-back patients”). Moreover, the importance of a good history and physical examination (including a pelvic exam) should not be ignored, most particularly in these cases.
The following case study highlights these central points and the necessity of a thorough work-up.
The patient, a 33-year-old woman, was seen in a local ED with complaints of increased vaginal discharge, vague abdominal pain, and odor that have persisted for "several days." Her vital signs were within normal limits. She was a poor historian, as she was unable to remember many details when asked. She stated that she may have had some burning on urination 3 days earlier. She denied any flank pain. She stated that she did not recall when the discharge began, but she reported that the abdominal pain began recently. Her voided urinalysis showed bacteria, scant white blood cells, positive squamous cells, and no nitrites. Her urine pregnancy test was negative. She was seen by a physician who diagnosed her with a urinary tract infection. The patient was discharged home with a prescription for sulfamethoxazole/trimethoprim double strength (Bactrim®). There was no documentation that a pelvic examination was performed.
After 2 weeks, the patient returned to the ED, at which time she was seen by a physician assistant (PA) who noted her chief complaint as vaginal discharge, abdominal pain, and pelvic pain. She stated that she had recently finished "some antibiotics." Her vital signs were again within normal limits. Her voided urine showed results similar to those seen at her first encounter. The PA performed a pelvic examination but did not note any obvious abnormalities. The patient was sent for a computed tomographic (CT) scan of the abdomen and pelvis, which was reported as showing nonspecific findings. Wet prep showed 1+ clue cells, 2+ white blood cells, and 0 yeast. The patient was diagnosed with bacterial vaginitis and pelvic inflammatory disease pending lab results. She was discharged home with a prescription for doxycycline and metronidazole (Flagyl®) after receiving a one-time intramuscularly administered dose of ceftriaxone (Rocephin®) 250 mg in the ED.
Four weeks later, the patient returned to the ED complaining of dyspareunia, increased pelvic/abdominal pain, and vaginal discharge. The patient described her pain as unique to her lower abdomen and pelvic area this time. During this encounter, the patient was seen by a nurse practitioner (NP), who documented a more detailed history and a more extensive physical examination, including a pelvic exam. It was noted on examination that the patient had increased tenderness upon palpation and inspection of the vaginal vault. A VFB was seen this time and documented by the NP. The VFB was noted as an almost unrecognizable tampon with malodorous, whitish discharge. It was removed without incident; there was a trace of bleeding and some mild discomfort to the patient. The patient appeared shocked to learn that there was a retained tampon in her vagina and could not recount previously forgetting to remove her tampon, nor could she recall any incident that would lead her to believe that there was a VFB accounting for her symptoms.