Premenarchal vaginal discharge: findings of procedures to rule out foreign bodies

Vaginoscopy to investigate vaginal bleeding and discharge in prepubertal girls

STUDY OBJECTIVE

To investigate the aetiology of vaginal bleeding and discharge in prepubescent girls, and the utility of vaginoscopy for making a diagnosis.

DESIGN

Retrospective observational study over 14 years.

SETTING

Two major tertiary referral paediatric hospitals in Sydney, Australia.

PARTICIPANTS

All prepubescent girls (n = 104) who presented with vaginal bleeding and/or discharge and subsequently underwent a vaginoscopy. A total of 120 procedures were performed.

MAIN OUTCOME MEASURES

Surgical findings at vaginoscopy; number needed to investigate (NNI) to establish a diagnosis and to exclude malignancy.

RESULTS

There were 52/120 (43.3%) vaginoscopies which provided a positive diagnosis, including 36/86 (41.8%) performed for bleeding and 16/34 (47.0%) for vaginal discharge. In the vaginal bleeding group, the causes found were a foreign body in 11/86 (12.7%), vulvovaginitis in 6/86 (6.9%), benign Mullerian papilloma in 5/86 (5.8%), trauma in 4/86 (4.6%), and malignant tumours in 2/86 (2.3%). To establish a diagnosis in girls presenting with vaginal bleeding, the NNI was 2.4; to detect a malignancy the NNI was 43.0. In girls presenting with vaginal discharge, vulvovaginitis was noted intraoperatively in 7/34 (20.6%) and a foreign body was found in 7/34 (20.6%). No malignant tumours were identified in the vaginal discharge group. To establish a diagnosis in girls presenting with vaginal discharge, the NNI was 2.1.

CONCLUSIONS

Vaginoscopy is an important diagnostic tool in the setting of vaginal bleeding in prepubescent girls, allowing the ability to confirm a diagnosis, and importantly, to exclude malignancy.

Intravaginal Foreign Body: A Rare Cause of Persistent Vaginal Discharge in a Child

ABSTRACT

Vaginal discharge is a common gynaecologic complaint in pre-menarchal girls. However, an intravaginal foreign body (FB) must be suspected when it is persistent. We report the case of a referred 4-year-old girl with a 5-month history of persistent foul-smelling vaginal discharge. Clinical examination confirmed purulent vaginal discharge, along with a vaginal granuloma. A hard, intravaginal object was felt through the anterior rectal wall on digital rectal examination. A plain pelvic X-ray revealed a radiopaque object whose intravaginal position was confirmed by ultrasonography. The patient underwent granuloma excision plus FB removal and antibiotic treatment. The 12-month follow-up was unremarkable.

Isolated Vaginal Bleeding Before the Onset of Puberty

Isolated vaginal bleeding before the onset of puberty is a rare presentation of isosexual precocity. In most cases, isolated vaginal bleeding without an abnormal genital examination is self-limited with resolution usually within 1 to 3 episodes. Watchful waiting is appropriate in most patients who do not have persistent bleeding, other signs of puberty, or signs/symptoms of an underlying etiology. Workup for patients with concerning features may include puberty hormone levels and/or transabdominal and transperineal ultrasound.

Vaginal foreign bodies in six nonhuman primates with underlying pathological conditions

Four female Japanese macaques (Macaca fuscata) from the same group as well as Wolf's guenon (Cercopithecus wolfi) and a Western lowland gorilla (Gorilla gorilla gorilla) from a second institution presented with vaginal foreign bodies in parallel with diseases of the urogenital tract or with endocrine disorders. These foreign bodies were associated with a mild to marked, diffuse vaginitis in all cases. Underlying pathological conditions consisted of a cavernous uterine hemangioma in a 20-year-old macaque, diffuse endometritis in a 21-year-old macaque, an in situ endometrial carcinoma in a 24-year-old macaque, endometritis and an ovarian cyst-like structure in the 27-year-old Western lowland gorilla, chronic cystitis and chronic renal disease in a 24-year-old macaque, and a history of hypothyroidism with irregular reproductive cycles in the 12-year-old Wolf's guenon. Vaginal foreign bodies have been reported in nonhuman primates used in biomedical research, but their concurrence with underlying conditions has not been explored. In women, vaginal foreign bodies have been linked to serious underlying medical conditions. This case series emphasizes the recommendation to investigate this abnormal behavior for underlying medical or adverse psychosocial conditions in primates under human care.

Clinical Features and Management of Urethral Foreign Bodies in Children: A 10-Year Retrospective Study

(1) Background: Urethral foreign bodies (UFBs) are very rare in children, and their treatment remains challenging. (2) Methods: A retrospective analysis was performed on 40 patients who were admitted to our hospital due to UFBs from June 2011 to June 2021. The clinical features and treatment experiences of these children are summarized. (3) Results: A total of 40 children were enrolled in the study, 17 boys and 23 girls. A majority of the boys (median age: 11.8 years) were of puberal age, and the main cause of the UFBs was sexual gratification (94.1%). Girls were almost always in early childhood (median age: 1.8 years), and most of the UFBs were related to specific clothing in specific regions and seasons. Ultrasound had a high accuracy in the diagnosis of female UFBs; the sensitivity and specificity were 88.9% and 85.7%, respectively. Most UFBs could be removed using a cystoscope (82.4% in boys, 100% in girls). All the children had a good prognosis and no complications occurred during follow-up. (4) Conclusions: Ultrasound is a reliable and sensitive method for the diagnosis of UFBs in girls. Cystoscopy is a reliable surgical method for UFBs.

Vaginal foreign bodies in children: a single-center retrospective 10-year analysis

OBJECTIVE

To evaluate the clinical features and outcome in girls with a vaginal foreign body.

METHODS

The clinical data of 97 girls with a vaginal foreign body were collected between 2010 and 2020. The descriptive analysis was used to summarize the clinical characteristics.

RESULTS

The patients were aged between 1.5 and 14.8 years, and the age of peak incidence was shown to be 3-10 years, which accounted for 88% of the cases. Blood-stained vaginal discharge or vaginal bleeding was the most common symptom (48%). The most common foreign bodies were small hard objects (57%), followed by bits of cloth or toilet tissue (22%). The patient whose foreign object was a disk battery had the most severe symptoms. When an injury of the vaginal mucosal was suspected, antibiotics were used to prevent infection, with full recovery of all patients without any additional treatment after removal of the foreign object.

CONCLUSION

If there is no damage to the vaginal mucosa, no additional treatment is needed after the foreign body is removed. When a vaginal foreign body is suspected to be a battery, emergency surgery is needed to prevent further damage.

Small spherical foreign bodies in the genitourinary tract and their management

Background

Urogenital small foreign bodies (FBs) have rarely been reported in children, and their management is still challenging. This study aimed to describe the characteristics and treatment of spherical FBs no larger than 0.6 cm in the children’s genitourinary tracts. 

Methods

The clinical data of spherical FBs removed in our hospital from June 2013 to June 2020 were recorded and retrospectively analyzed, including demographics, location, symptoms, imaging examinations and treatment methods.

Results

A total of 10 patients were enrolled: 6 girls and 4 boys. Their ages ranged from 5.1 to 16.8 years old, with a mean age of 9.2 years. The course of the disease ranged from 3 h to 1 year, and symptoms recurred in some cases. Their imaging characteristics were reviewed and analyzed, 6 patients underwent color Doppler ultrasonography, 1 patient was suspected to have an FB in the vagina, 7 patients underwent an X-ray examination, and FBs were revealed in 6 patients. All FBs were removed under endoscopic minimally invasive surgery. Six vaginal FBs were successfully retrieved via vaginoscopy, and in the other four cases, removal by transurethral cystoscopy failed because of mutual attraction, which was eliminated by laparoscopy under pneumovesicum. Postoperative recovery was uneventful; in a follow-up of 3 months to 2 years, there was no perforation or fistula formation, and there were no urethral strictures in boys.

Conclusion

Small spherical FBs are clinically rare; they are sometimes difficult to detect by imaging examinations and can be easily overlooked. Minimally invasive endoscopy remains the first-line approach for the diagnosis and removal of genitourinary spherical FBs.

Cotton fiber ball as an unusual cause of vaginal discharge in a 5-year-old child

Vaginal discharge in children can be due to many causes. Foreign body in vagina is an unusual cause. Foul-smelling, blood-stained vaginal discharge should raise the suspicion of foreign body in vagina. Magnetic resonance imaging (MRI), vaginal examination under general anesthesia may detect foreign bodies in vagina. We found a cotton fiber ball in vagina, probably caused by the child's teddy bear as a cause of vaginal discharge in a 5-year-old child. A repeat MRI suggested foreign body in the vagina and vaginal exploration under general anesthesia helped for the removal of cotton fiber ball, which led to complete clearance of the vaginal discharge in the child.

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

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.

Rare Pediatric Vaginal Granular Cell Tumor: A Case Report

BACKGROUND

Granular cell tumors (GCTs) are usually benign and occur primarily in the trunk and head. Vaginal tumors are rare, particularly in children.

CASE

A 9-year-old girl was admitted with irregular vaginal bleeding for 1 year. The bleeding had worsened in the previous 1 month. B-ultrasound and computed tomography showed a round mass in the vagina. We performed vaginoscopy using a hysteroscopic exploration and tumor resection via an open technique. The pathology of the resected tumor confirmed a vaginal wall GCT. No recurrence was noted in the following 16 months.

SUMMARY AND CONCLUSION

To our knowledge, our prepubescent girl is the youngest patient with GCT in the literature. Histopathological evaluation and complete tumor resection with clear margins is the primary treatment for benign or malignant GCTs.

Vaginal Bleeding in Pre-pubertal Females

STUDY OBJECTIVE

Puberty is a normal process for adolescents, and the first signs may include change in body odor, breast development, or pubic hair growth. This is then followed by menarche approximately 2 years later. Vaginal bleeding in pre-pubertal female individuals is rare. The aim of this study was to investigate causes of pre-pubertal bleeding in a group of patients.

DESIGN, SETTING, METHOD, AND MAIN OUTCOME MEASURES

Seventeen patients who presented with pre-pubertal recurrent vaginal bleeding with no other signs of precocious puberty were investigated, to determine the cause of this symptom.

RESULTS

The mean age for the onset of vaginal bleeding was 7.4 years, ranging from 4 to 9.67 years. Gonadotrophin-releasing hormone (GnRH) stimulation tests showed a pre-pubertal response in all cases. Pelvic ultrasound scans showed a pre-pubertal uterus in all patients. Two patients were found to have foreign bodies identified during a genital examination under anesthetic, and in both cases removal of the foreign bodies terminated the vaginal bleeding.

CONCLUSION

In conclusion, recurrent vaginal bleeding was not associated with GnRH response, raised estradiol levels, or abnormal pelvic ultrasound findings. In cases of recurrent vaginal bleeding with normal hormonal investigations in pre-pubertal girls, it is recommended that a genital examination under anesthetic be undertaken to rule out undiagnosed causes of the presenting symptom.

Psychiatric referral is required in children with vaginal foreign body injury: A case-control study from China

PURPOSE

The rate of vaginal foreign body (VFB) injury has been increasing in recent years. VFB will cause vaginal inflammation, injury and negative psychological impacts in girls. Our study aimed to elucidate the need of psychological referral in children with VFB.

DESIGN AND METHODS

A case-control study was performed. A total of 67 girls who visited the clinic due to vaginal foreign bodies were recruited. A questionnaire and Family environment scale-Chinese version (FES-CV) and social anxiety scale for children-Chinese version (SASC-CV) were completed by parents and children. Demographic information, parenting pattern, girls' social anxiety status, and their daily life trajectory and outdoor activities were collected.

RESULTS

The mean age of the 67 girls with VFB was 6.6 ± 2.1 years with a range of 2 years10 months-13 years. The 72 girls of the control group were age-matched with the patients. Scorings in two subscales of FES-CV including family cohesion, emotion expression were significantly lower in the VFB group than those in the control group (7.2 ± 2.4 vs. 7.9 ± 1.7, p < 0.05; 5.2 ± 1.6 vs. 6.5 ± 1.3, p < 0.001). Social anxiety level was higher in the VFB group comparing with the control group. Shorter time of outdoor activities (t = 3.205, p = 0.002) and significantly longer screen time were in the VFB group (t = 5.74, p < 0.001).

CONCLUSIONS AND IMPLICATIONS

The occurrence of VFB was associated with parenting patterns and social anxiety level. Psychiatric referral is required in children with VFB.

Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology

Vulvovaginitis is one of the most common gynecological complaints presenting in the pediatric and adolescent female. The common causes of vulvovaginitis in the pediatric patient differ than that considered in adolescent females. When a child present with vulvar itching, burning and irritation the most common etiology is non-specific and hygiene measures are recommended. However these symptoms can mimic more serious etiologies including infection, labial adhesion, lichen sclerosis, pinworms and foreign body must be considered. Yeast infection is rare in the pediatric population but common in the adolescent. In the adolescent patient infections are more common. Yeast and bacterial vaginosis are commonly seen but due to the higher rate of sexual activity in this population sexually transmitted infections must also be considered.

Clinical presentation, diagnosis and treatment of vulvovaginitis in girls: a current approach and review of the literature

BACKGROUND

Vulvovaginitis is the most common cause of gynecological complaints in children and young girls. Some of the factors which cause vulvovaginitis include hypoestrogenism, the anatomical proximity of rectum and delicate vulvar skin and vaginal mucosa.

DATA SOURCES

We made a literature search with Pubmed, Medline and Cochrane database from January 2002 to May 2015 in English language using the key words vulvovaginitis, children, clinical, diagnosis and treatment.

RESULTS

Vulvovaginitis in girls is usually caused by non-specific factors and hygiene measures, bioyoghurt and avoidance of chemical irritants are generally useful. Weight control if necessary and prevention of voiding dysfunction are effective. Vaginal flora is important in girls and results should be interpreted with clinical features to decide whether an isolated microorganism is part of the normal microflora or is the cause of symptomatic vulvovaginitis. Specific treatment is generally considered in case of a detected pathogen microorganism. Isolation of a sexually transmitted organism requires further investigation. Persistent disease may not always indicate a foreign body but it must be taken into account. Girls and parents are encouraged psychologically in all steps of evaluation, diagnosis and treatment. Probiotics, nanotechnology and petroleum jelly are other important treatment options used in vulvovaginitis.

CONCLUSIONS

In this review, we present current approach to the presentation and management of vulvovaginitis in childhood. This disorder requires a comprehensive evaluation in all steps of diagnosis, differential diagnosis and treatment.

Prepubertal Vaginal Bleeding: Etiology, Diagnostic Approach, and Management

IMPORTANCE

Prepubertal vaginal bleeding outside the neonatal period is always abnormal and is very alarming to parents. A variety of practitioners, including obstetrician-gynecologists and pediatricians, may be asked to see patients with this presenting complaint, yet many do not receive adequate training in pediatric gynecology.

EVIDENCE ACQUISITION

Review of the published literature in PubMed, focusing on the last 20 years, regarding the incidence, etiologies, diagnosis, and management strategies for the common causes of prepubertal vaginal bleeding.

RESULTS

Careful history taking and pediatric-specific gynecological examination skills, including awareness of normal anatomy across the age spectrum and the ability to identify an estrogenized hymen, are keys to the appropriate assessment of this clinical problem.

CONCLUSIONS AND RELEVANCE

Prepubertal vaginal bleeding has many causes and requires a thorough targeted history and pediatric genitourinary examination, requiring knowledge of the variants of normal pediatric genitourinary anatomy. Most causes can be easily treated and are less likely to be due to sexual abuse or malignancy.

Personal Hygiene and Vulvovaginitis in Prepubertal Children

STUDY OBJECTIVE

To determine and compare clinical and microbiological features of vulvovaginitis in prepubertal girls. Vulvovaginitis is the most common gynecological problem of childhood. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This study involved 45 girls from 2-12 (5.38 ± 2.9) years old; and 26 girls from 3-12 (5.72 ± 3.1) years old as a control group. Anamnesis and physical examination were followed by vaginal smear, urine culture, and stool analyses from both groups, and the personal hygiene status and education level of the mother were determined.

RESULTS

The most common symptoms among the patients were vaginal discharge (44.4%, vulvar erythema (37.8%), and vaginal itch (24.4%). Microorganisms, isolated from vaginal smears, were detected in 48.9% of the patients. Escherichia coli was shown in the urine culture of 3 patients with vulvovaginitis (6.70%). In microscopic stool analysis parasites were detected (45.9%). We found some relevant personal hygiene factors, such as wiping back to front (42.9%), cleaning by herself after defecation (89.3%), using toilet paper (60.7%) and wet wipes (21.4%), and bathing standing (14.3%) and sitting (46.4%) among patients. The questionnaire also showed that the children wore tight clothing (35.7%).

CONCLUSION

Our findings suggest that vulvovaginitis in prepubertal girls is related not only to microorganisms but also poor personal hygiene, the educational status of mothers, and specific irritants.

A rare case of foreign body causing recurrent vaginal discharge in prepubertal child

Vaginal discharge in prepubertal children is mainly due to hypoestrogenic state of vaginal mucosa making it thin and alkaline leading to mucosal invasion by pathogen. In a paediatric case with persistent foul smelling , blood stained vaginal discharge not responding to medical therapy, vaginal foreign body should always be ruled out. Here, we report a 3 -year -old girl with complaint of recurrent vaginal discharge occasionally blood stained not relieved despite few antibiotics courses. On X -ray pelvis, a radioopaque foreign body hair clip was seen. Under sedation foreign body was removed by forceps following which child became asymptomatic.

Use of hysteroscope for vaginoscopy or hysteroscopy in adolescents for the diagnosis and therapeutic management of gynecologic disorders: a systematic review

STUDY OBJECTIVE

The purpose of this article is to review the published literature and perform a systematic review to evaluate the effectiveness and feasibility of the use of a hysteroscope for vaginoscopy or hysteroscopy in diagnosing and establishing therapeutic management of adolescent patients with gynecologic problems.

DESIGN

A systematic review.

SETTING

PubMed, Web of science, and Scopus searches were performed for the period up to September 2013 to identify all the eligible studies. Additional relevant articles were identified using citations within these publications.

PARTICIPANTS

Female adolescents aged 10 to 18 years.

RESULTS

A total of 19 studies were included in the systematic review. We identified 19 case reports that described the application of a hysteroscope as treatment modality for some gynecologic conditions or diseases in adolescents. No original study was found matching the age of this specific population.

CONCLUSIONS

A hysteroscope is a useful substitute for vaginoscopy or hysteroscopy for the exploration of the immature genital tract and may help in the diagnosis and treatment of gynecologic disorders in adolescent patients with an intact hymen, limited vaginal access, or a narrow vagina.

An unexpected cause of vaginal bleeding: the role of pelvic radiography

Vaginal bleeding and/or discharge in young girls may result from infection, urological problems, endocrine causes, bleeding disorders, dermatological conditions, trauma, sexual abuse, masses or foreign bodies. We report a case of excessive vaginal bleeding caused by a foreign body in a prepubertal girl with emphasis on the diagnostic challenges and pitfalls regarding imaging techniques. In our patient, although invasive and expensive investigations had been initially made, the foreign body was last detected only when a plain pelvic radiography was performed.

Recurrent vaginal discharge in children

BACKGROUND

Childhood vaginal discharge remains a frequent reason for referral from primary to secondary care. The Pediatric and Adolescent Gynecology (PAG) service at Kettering General Hospital was established in 1993 and provides a specialized service that meets the needs of children with gynaecological conditions.

AIM

To investigate recurrent vaginal discharge noting symptomatology, defining pathogens, common and rarer causes, exploring management regimes, and any changes in practice over time.

METHOD

Retrospective review spanning 15 years identifying prepubertal children attending the outpatient PAG clinic with recurrent vaginal discharge. We reviewed the medical notes individually.

RESULTS

110 patients were identified; 85% were referred from primary care. The age distribution was bimodal at four and eight years. Thirty-five percent of our patients were discharged after the initial consultation. The commonest cause of discharge was vulvovaginitis (82%). Other important causes included suspected sexual abuse (5%), foreign body (3%), labial adhesions (3%), vaginal agenesis (2%). 35% of patients were admitted for vaginoscopy.

CONCLUSION

Vaginal discharge is the most common gynecological symptom in prepubertal girls and can cause repeated clinical episodes. Vulvovaginitis is the most common cause and often responds to simple hygiene measures. Awareness of the less common causes of vaginal discharge is essential.

Rectorrhagia and vaginal discharge caused by a vaginal foreign body--a case report and review of literature

An 8-year-old girl was taken to an outpatient clinic of surgery suffering from rectorrhagia and purulent, smelly vaginal discharge. Colonoscopy and biopsy were done before referring and sulfasalazine regime was administrated for probable colitis. The surgeon performed a rigid rectosigmoidoscopy under general anesthesia and no positive evidence was found. Having examined the hymen, it was found to be intact but a purulent discharge was observed. After drying the discharge, a black foreign body was seen in the bottom of the vagina and brought out by a fine forceps. It was a toy's wheel. The patient and her mother both denied foreign body abusing history. It was recommended she go for a psychological consultation. Generally speaking, all young patients suffering from vaginal or rectal bleeding with or without discharge should have their vagina checked for a foreign body. What is recommended in such cases is to undergo sonography or plain radiography before considering invasive or non-invasive procedures for evaluating anal and sigmoid abnormalities. Last but not least, a vaginal irrigation, precise examination of hymen, and posterior fossa can prove very useful for detecting simple vaginal bodies that can lead to various vaginal, rectal and abdominal complications.

Vaginal foreign body: Successful management with vaginoscopy

The etiology of chronic vaginal discharge in children varies and can be seen as infection, sexual abuse, congenital malformations, vulvar skin disease, vaginal neoplasms and a foreign body. A vaginal foreign body is not a common problem in childhood but it should always be considered when a little girl consults a physician with a chronic vaginal discharge problem. We present the diagnosis and treatment management via vaginoscopy applied to a 6 year old girl who complained of a foul smelling vaginal discharge that had been resistant to medical treatment for the last two years.

The role of examination under anesthesia (EUA) and vaginoscopy in pediatric and adolescent gynecology: a retrospective review

BACKGROUND

Examination under anesthesia (EUA) with diagnostic vaginoscopy is an invaluable method in the lower genital tract assessment of pediatric and adolescent females. The literature on this topic remains scarce.

METHODS

This is a retrospective medical notes review of all patients who underwent EUA with or without vaginoscopy over the past 5 years at a pediatric and adolescent gynecology unit specializing in disorders of sex development (DSD).

RESULTS

From 2005 to 2010, 83 patients underwent 92 procedures. All procedures were performed under general anesthesia, and a 3-mm pediatric cystoscope was used for vaginoscopy. Of the 92 cases, 33 (36%) were EUA alone and 59 (64%) consisted of a combined EUA and vaginoscopy. The mean age was 13.3 ± 3.7 years. The most common indications included assessment for reconstructive surgery (33.7%), vaginal stenosis (21.7%), vaginal discharge (19.6%), vaginal bleeding (16.3%), and pelvic pain (8.7%). Most (61%) of those presenting for assessment for reconstructive surgery had a DSD and history of surgical correction in early childhood. In 88 cases (96%), the evaluation was satisfactory and a diagnosis was reached or normality confirmed. Four cases (4%) required further investigation. No significant intraoperative or postoperative complications were encountered. Of the 92 cases, 15 (16%) required a further minor procedure, which was performed at the time of the EUA/vaginoscopy. Another 33 (36%) required further major surgery, which was performed at a later date.

CONCLUSION

EUA/vaginoscopy is a safe and highly useful method in the assessment of the lower genital tract in pediatric and adolescent patients.

Voiding dysfunction: another etiology of vulvovaginitis in young girls

OBJECTIVE

To determine the prevalence of voiding dysfunction (VD) in patients with persistent vulvovaginitis (PVV), and to evaluate the clinical response of PVV in the treatment of VD.

PATIENTS AND METHODS

Girls four years or older who consulted for PVV for at least one month and who did not respond to general measures. A physical examination was performed with visual inspection and colposcopy; vaginal samples for culture and vaginoscopy were carried out. On every patient urodynamic studies were performed. Girls who were diagnosed with VD were treated. A pediatric gynecologist did the follow-up; a successful response was considered when inflammatory symptoms and vaginal discharge ceased.

RESULTS

Twenty patients were included, mean age 8.6 years (range: 4.6-14 years); 75% prepubertal symptoms lasted for 1.8 years; 19 (95%) had urodynamia, 10 (52.6%) had an overactive bladder, 8 (42.1%) external bladder sphincter dyssynergia, 1 (5.2%) hypotonic bladder, and 13 (65%) showed improvement.

CONCLUSION

VD is an important cause when considering the etiology of PVV.

Long-retained vaginal foreign body causing chronic vaginitis in a bulldog

A vaginal foreign body consisting of a piece of retained calvarium from a macerated fetus was identified and removed using vaginoscopy in a 4-year-old, spayed female bulldog. The dog had a 12-month history of chronic mucopurulent vaginitis. Vaginal foreign bodies, although uncommon, are a differential diagnosis for recurrent mucopurulent or hemorrhagic chronic vaginal discharge. A case of chronic vaginitis caused by a long-retained intravaginal foreign body in a dog is described and compared to four other canine cases reported in the literature.

Foreign objects in the vagina of a mentally ill woman: case series

OBJECTIVE

Reports of the insertion of foreign objects to the vagina by psychiatric patients are scant. We present two such cases.

METHODS

Case I resulted from psychotic content and auditory command hallucinations. Case II -- the patient, in a manic state used her vagina as a hiding place for keys she stole from a staff member.

RESULTS

Both cases required gynecological intervention.

CONCLUSIONS

Medical cooperation between psychiatrists and gynecologists was necessary in order to achieve improvement in both the physical and mental conditions of the patients and in order to plan programs for continued care.