(57) Fistula Formation from Chronic Presence of a Vaginal Foreign Body

Background: Small vaginal foreign bodies (FB) in adolescent girls are common, resulting in simple outpatient removal without major sequelae. However, persisting FBs can result in serious complications, such as becoming deeply embedded, perforations, fistula formation involving multiple organs, and needing complex surgeries.

Case: This 16-year-old female was transferred from a community hospital due to a CT scan concerning for FB. Her history revealed that she had inserted a shampoo bottle pump into her vagina at age 11. She reported four years of intermittent right lower quadrant abdominal pain, and more recently, dark, foul-smelling vaginal discharge. Her parents were not aware of her symptoms until transfer of care. She denied fevers, chills, or vomiting.

CT scan of the abdomen/pelvis revealed a rectovaginal fistula with stool in the vagina and FB migration into the rectum. Pediatric surgery and pediatric adolescent gynecology teams did a joint procedure in the operating room for examination and removal under anesthesia. On digital rectal exam, a 3-centimeter FB was palpated, but physical extraction was difficult due to scar tissue. Proctoscopy was unsuccessful in visualizing it, so gastroenterology was consulted. Colonoscopy showed a portion of the FB in the rectum.

A proximal colotomy was made; a piece of the FB was removed through the colon. Scar tissue in the posterior fornix was dissected, allowing for further removal of a 3-centimeter portion of the FB from the vaginal mucosa. Because the FB was seen both vaginally as well as in the colon and rectum, a large rectovaginal fistula was suspected.

The FB did not enter the peritoneal cavity. The cervix was intact. The bladder was backfilled with methylene blue with no spillage in the vagina or abdomen. The entire FB was reconstructed on the table, indicating complete removal. Intraoperative fluoroscopy showed no residual FB. Due to significant inflammatory changes around the rectovaginal fistula with no clear planes, immediate repair was not attempted. A diverting loop sigmoid colostomy was formed, and the abdomen was closed. The patient was transferred to the ICU and discharged home on POD#7.

Comments: This case is unique because it reveals the long-term sequelae of persistent FBs. It is also unusual as the patient is an older adolescent. This patient may have been at higher risk for these serious complications due to history of self-injury, suicidal ideation, and social factors such as home-schooling, which may have contributed to social isolation. Due to the large span of time, these long-standing FBs require a multidisciplinary approach, including imaging and a unique surgical approach for removal.