Discussion

While the patient may have be unwilling or unable to provide accurate historical details initially, the diagnosis of VFB hinges on thorough detail that may come after the initial work-up. Patients may honestly not remember a retained foreign body and the unique anatomy may not readily alert the patient to the fact that a VFB is present.


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The most common symptom in these cases is the production of increased vaginal secretions.3 Unfortunately, increased vaginal secretions and vaginal discharge is a nonspecific symptom of various medical problems and a common gynecologic complaint by women.5 In the case study, a pelvic examination was not performed until the patient returned for a second time to the ED, and then, nothing abnormal was seen by the provider. This might be attributed to a wide variety of factors including the clinical expertise of the provider, the skill of the provider in performing pelvic exams, the natural course of progression of the foreign body itself, or the fast-paced environment of the ED, which can lead to some providers not being as thorough as possible when faced with multiple patients being treated at the same time and a lobby full of patients waiting to be seen. Time can be saved by not performing a pelvic exam, especially when VFB is low on the list of possible conditions or when VFB is mistakenly excluded.

In the case study, a CT of the abdomen and pelvis was ordered and obtained; however, this was done to exclude any abdominal pathology. The fact that the VFB was not detected by CT perhaps illustrates another important point: there is documentation in the literature that magnetic resonance imaging (MRI) is the best modality for the detection of VFBs.5 Nonetheless, since MRIs are frequently difficult to obtain due to cost, they may be discouraged in the ED setting.  In addition, as providers may be required to obtain approval prior to ordering the study, they may not be routinely ordered. Bedside ultrasound has also been documented in the literature as a good choice for detection of VFB.6

As clinicians, we must remember that a thorough history and physical examination will help us to recognize both the horse and the zebra. Unfortunately, sometimes the historical details only become clearer as the symptoms progress or on subsequent evaluation of bounce-back patients. Hawkins et al7 identified a list of pertinent questions clinicians should consider when conducting a patient interview, including an obvious question about whether or not the patient uses tampons, which can be easy to forget to ask in clinical practice if VFB is not high on your list of differential diagnoses.

In this case, a zebra was missed due to several factors, most importantly, the initial lack of a thorough history and physical examination. Clinicians must be aware that when this type of bounce-back patient presents to the ED, the zebra diagnosis of VFB must be placed high on the list of potential diagnoses.

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Patrick Ayarzagoitia, DNP, APRN, FNP-BC, is the CEO, professor, and founder of Education for Advanced Practice, LLC, the mission of which is to provide low-cost, high-quality education for advanced practice providers and students.  Dr Ayarzagoita also works in the emergency department for Schumacher Clinical Partners.

References

  1. Amidat A, Taylor A. Unusual presentation of vaginal foreign body. J Obstet Gynecol. 2010;30(8):873-875.
  2. Raphaelidis L. Uncommon vaginitis cases: expect the unexpected. J Nurse Pract. 2015;11(1):135-138.
  3. Nwosu EC, Rao S, Igweike C, Hamed H. Foreign objects of long duration in the adult vagina. J Obstet Gynaecol. 2005;25(7):737-739.
  4. Smith CS, Paauw DS. When you hear hoof beats:  four principles for separating zebras from horses. J Am Board Fam Pract. 2000;13:424-429.
  5. Nanda S, Malhotra V, Yadav S, et al.  Foreign body in the vagina mimicking a transverse vaginal septum. J Gynecol Surg. 2014;30(6):386-389.
  6. Sivitz A. Ultrasonography: expanding bedside applications in the pediatric emergency department setting. Contemp Pediatr. 2011;28(4):48-58.
  7. Hawkins JW, Roberto-Nichols DM, Stanley-Haney JL (eds). Bacterial vaginosis. In: Guidelines for Nurse Practitioners in Gynecologic Settings, 10th ed. New York; Springer Publishing Company; 261-262.