(129) Urethro-vaginal Fistula in the Setting of a Vaginal Foreign Body - Diagnosis and Treatment

Background: Vaginal foreign bodies are a rare but important cause of persistent genitourinary complaints in the pediatric and adolescent population. Most foreign bodies are easily removed with vaginoscopy or lavage. There are few reported cases of fistula formation due to vaginal foreign body, with even fewer being in the pediatric population.

Case: An 11-year-old girl presented to the emergency department (ED) after a vaginal foreign body was incidentally noted on a scoliosis screening x-ray. During the ED visit she reported vulvovaginal discharge, odor, perineal skin changes, and urinary incontinence. She was previously seen for the these complaints by primary care (PCP) and urgent care on three occasions during which she had external genital visual exams and bacterial vaginosis treatment. Her first visit for these concerns was 2/2022, at which time she screened negative for sexual abuse in the setting of multiple foster homes. She was seen by a new PCP 6/2022 when XR was ordered and showed the object (pencil sharpener). During the ED visit, the patient readily disclosed that she placed the object in her vagina one year prior. She was scheduled for an exam under anesthesia (EUA) after unsuccessful removal in the ED and gynecology office. Foley catheter placement at the beginning of the case was notable for the catheter passing from the urethra into the vagina. The pencil sharpener was embedded through the anterior vaginal wall and required removal in pieces using orthopedic Rongeur forceps to crush the object. Intraoperative Urology consultation confirmed urethrovaginal fistula via cystoscopy. A multidisciplinary plan was made for follow up EUA, cystoscopy, vaginoscopy for operative planning; the fistula was 1cm and just distal to the bladder neck. Two months later she underwent repair of the urethrovaginal fistula and suprapubic catheter placement. EUA, cystoscopy, vaginoscopy was performed post-operatively and confirmed complete healing.

Comments: In pediatric patients presenting with persistent vulvovaginitis and urinary complaints, vaginal foreign body should be considered and screened for. Genital exam with labial traction is crucial for visualization of the lower vagina, allowing for more expeditious detection of a foreign body. If unable to visualize a foreign body with external exam/labial traction, a vaginal lavage or EUA with vaginoscopy is recommended. When a foreign body requires surgical removal, it is prudent to assess for fistula formation, with multidisciplinary care if a fistula is identified. Children with complex social situations are a vulnerable population at risk for disjointed care and delayed diagnoses.