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A rare C.T. scan finding of foreign body vagina, a hard fruit, kept as Pessary for uterine prolapse.

INTRODUCTION: Pessaries are designed to press against the wall of the vagina to uplift and displace the bladder forward or to support a prolapsed uterus or vagina. (1) Modern day pessaries come in a wide range of shapes, sizes and different designs and different materials.

Pessaries have been used by women for centuries to manage pelvic organ prolapse. Reports of pessary use date back to ancient Egypt and ancient Greeks. Hippocrates described the use of pomegranates soaked in vinegar as vaginal pessary. Over the ages women have used a variety of materials for pessary support including fruits, stone, soaked cloth, cork, brass and rubber. Most of these materials were in ball oval or ring form. (2)

Rubber was discovered in the 18th century and was found to be more suitable for vaginal placement. In the middle of 20th century rubber was replaced by plastic. More recently, silicon has replaced other materials for vaginal pessaries and approximately 20 types of either supportive or space filling pessaries are used worldwide. (3)

CASE REPORT: A female patient aged about 55yrs, para 9 came to department of radio-diagnosis for ultra sound scan with clinical diagnosis of vague pain abdomen. Ultra sound reveals hyper echoic curvilinear shadow posterior to urinary bladder. X-ray KUB was taken and shows radio opaque ring in the pelvis. C.T scan shows hyperdense ring lesion with air fluid level in the vagina.

On per vaginal examination, a hard foreign body is felt in the vagina probably wood apple. Under spinal anesthesia foreign body is removed, which is a hard fruit botanically named as Aegle marmelos, commonly called as bili fruit in bengali and maredu fruit in telugu and bilva fruit in sanskrit.

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Fig. 2: Contrast CT image of the pelvis shows thick hyperdense ring lesion with air fluid level within. The hyperdense ring lies between contrast filled bladder anteriorly and rectum posteriorly.

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DISCUSSION: In developing countries pelvic organ prolapse is a very common cause of reproductive morbidity among women. Most women do not seek medical attention due to shyness, lack of family support or poverty. There are a few cases of impacted ring in -situ for years. (4) Keeping hard fruits in the vagina to prevent uterine prolapse is being practiced by quacks in villages and few cases were reported by gynecologists in Rayala seema area of Andhra Pradesh.

Although neglected foreign bodies in vagina are rare in adults, there have been several cases found in adult 5 8 and among them majority of cases of foreign bodies are found in children. (9,10) Toys, metallic glasses, screws, hair sprays, plastic covers, drinking glass etc. have been found to be in vagina. Serious complications like fistula formation (7) and bowel obstruction (8) have been reported with retained foreign body vagina. There are reported cases of recto vaginal fistula, developing secondary to a forgotten vaginal pessary, but in this patient, no complications were identified even after 5yrs of placement of vaginal foreign body i.e., fruit.

Although many types of pessaries exist, they are commonly large thick-rimmed rings of uniform high density perpendicular to the plane of the vagina on MDCT imaging. (11) In the simple radiography pessary usually presents as a rounded structure, with donut shaped with soft tissue density and a thin halo of air density on its inner margin.

CONCLUSION: There are multiple foreign objects of habitual use which can be found in the vaginal cavity in simple radiology, computed tomography and magnetic resonance studies. The knowledge of them avoids misinterpretation of images and confusion with adjacent pathology. If any ring lesion seen in radiograph of pelvis or hyperdense ring lesion with air fluid level in vagina in C.T. scan, should think of differential diagnosis of a fruit in vagina used as pessary to prevent uterine prolapse.

DOI: 10.14260/jemds/2014/2741

REFERENCES:

(1.) Hunter TB, Taljanovic MS. Medical devices of the abdomen and pelvis. Radio Graphics 2005; 25(2): 503-523.

(2.) Bash KI. Review of vaginal pessaries. Obstet Gynecol Surv 2000; 55:455-460.

(3.) Vierhout ME. The use of pessaries in vaginal prolapse. Eur J Obstet Gynaecol Reprod Biol 2004; 117:4-9.

(4.) Malatyalioglu E, Alper T, Kokoo. An intravaginal foreign body of over 25 years' duration. Acta Obstet Gynecol Scand 1999: 78; 616-17.

(5.) Malatyalioglu E, Alper T, Kokoo. An intravaginal foreign body of over 25 years' duration. Acta Obstet Gynecol Scand 1999: 78; 616-17.

(6.) Nwosu EC, Rao S, Igweike C, Hamed H. Foreign objects of long duration in the adult vagina. J Obstet Gynaecol 2005; 25(7):737-39.

(7.) Biswas A, Das HS. An unusual foreign body in the vagina producing vesicovaginal fistula. J Indian Med Assoc 2002; 100(4):257-59.

(8.) Puneet, Khanna A, Khanna AK. Intravaginal foreign body--a rare cause of large bowel obstruction. J Indian Med Assoc 2002; 100(11):671.

(9.) Stricker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J Paediatr Child Health 2004; 40(4):205-7.

(10.) Dahiya P, Agarwal U, Sangwan K, Chauhan M. Long retained intravaginal foreign body: a case report. Arch Gynecol Obstet 2003; 268(4): 323-24.

(11.) Elizabeth V, Silaja, Chrystia M, Genevieve L. Commonly encountered foreign bodies and devices in the female pelvis: MDCT appearances. AJR 2011; 196:W461-W470

AUTHORS:

[1.] K. Radha Rani

[2.] B. Sarada

[3.] S. Shamshad Begum

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of Radiodiagnosis, Government Medical College, Ananthapuramu.

[2.] Assistant Professor, Department of Radiodiagnosis, Government Medical College, Ananthapuramu.

[3.] Associate Professor, Department of Obstetrics and Gynaecology, Government Medical College, Ananthapuramu.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. K. Radha Rani, D. No. 11/127/6, Besides Jesus Nagar Current Office, Government Medical College Staff Quarters, Ananthapuram--515001, A. P.

Email: drradharanikaki@gmail.com

Date of Submission: 24/04/2014. Date of Peer Review: 25/04/2014. Date of Acceptance: 05/05/2014. Date of Publishing: 04/06/2014.
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Title Annotation:ORIGINAL ARTICLE
Author:Rani, K. Radha; Sarada, B.; Begum, S. Shamshad
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Jun 9, 2014
Words:989
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