Long-Retained Vaginal Foreign Body Causing Chronic Vaginitis in a Bulldog

Introduction

Vaginal foreign bodies are rare, and they can be challenging to detect; therefore, they may remain undiagnosed for long periods of time.^1–4 Vaginal foreign bodies can cause intense inflammation and give rise to persistent or intermittent vaginal bleeding or mucopurulent, malodorous vaginal discharge.^1–4 Medical imaging and vaginoscopy are key to ruling out a vaginal foreign body as the underlying cause for persistent or recurrent vaginitis.^3,5 A case of a long-standing vaginal foreign body in a dog is described and compared to three other canine cases reported in the literature.

Case Report

A 4-year-old, 24.8-kg, spayed female bulldog was referred to the Western College of Veterinary Medicine Small Animal Teaching Hospital with an 11-month history of chronic mucopurulent vaginitis. Fourteen months prior to referral, the dog had been bred by artificial insemination, and 45 days later she was presented to her referring veterinarian (RDVM) for evaluation for pollakiuria and dysuria. Pyuria and struvite crystalluria were noted on urinalysis of a sample collected by cystocentesis. A 10-day oral course of amoxicillin-clavulanic acid (dose not specified) was prescribed.^a A follow-up urinalysis, performed the day after the prescribed course of antibiotics ended, was normal. Abdominal radiography, performed during the same follow-up appointment to determine the number of expected puppies, revealed seven fetuses. No evidence of radiopaque uroliths existed. Sixty-two days after breeding, the dog underwent an elective cesarian section (C-section). Seven puppies were delivered; six were live and one was stillborn. Three weeks after the C-section, the dog was presented to the RDVM with clinical signs of mastitis (swollen, red, painful mammary glands) and vaginitis (mucopurulent vaginal discharge). Treatment with amoxicillin-clavulanic acid was initiated (orally for 14 days, dose not specified), and both conditions resolved. The vaginal discharge returned a few days after the course of antibiotics was completed.

Six weeks after the C-section, an ovariohysterectomy (OHE) was performed by another primary care veterinarian who suspected an open pyometra as the cause of the dog’s recurrent mucopurulent vaginal discharge. No information was noted in the dog’s medical record regarding the gross or histological ovarian or uterine pathology. Despite the dog’s OHE, vaginal discharge did not resolve. A stump pyometra was suspected by the original RDVM, and an exploratory celiotomy was performed 47 days after the OHE. A 1-cm uterine stump embedded in connective tissue and fat was detected, but no significant gross abnormalities were seen. Ampicillin^b (500 mg) diluted in sterile saline was injected into the dog’s uterine stump prior to routine closure of the abdominal incision. Also at the time of surgery, the dog’s vagina was lavaged with 500 mL of dilute Betadine^c followed by 180 mL of 0.9% sterile saline using a urinary catheter inserted retrograde into the vagina. The dog was discharged and prescribed a 4-week course of oral difloxacin hydrochloride^d (dose not specified). The dog was treated on and off for 6 months with various systemic antibiotics (not specified) and dilute Betadine douches. Each time a course of antibiotics was administered, the vaginal discharge would resolve only to recur a few days after finishing the course of antibiotics. Shortly after finishing the last course of antibiotics prescribed by the RDVM, the dog’s vaginitis recurred. Thus, 11 months after this dog’s C-section, she was referred for further diagnostics. The RDVM’s tentative diagnosis was a chronic vaginitis or a recurrent lower urinary tract infection (LUTI) caused by an anatomical abnormality or stump pyometra.

At the time of referral, the owners reported the dog was posturing normally to urinate, and no signs of stranguria were present. They did, however, report pollakiuria. No systemic clinical signs of disease had been noted, but the owners felt that for the previous 8 to 12 months the dog had been reluctant to stand for lengthy periods of time. The dog preferred to sit whenever possible and would drag her hind end if she was forced to exercise strenuously. The dog had no pertinent travel history. Temperature, pulse, and respiratory rate were within normal limits, but the dog was overweight with a body condition score of 7/9. A moist nasal-fold pyoderma and an inspiratory stertor, both attributable to brachycephalic conformation, were present. A malodorous, mucopurulent vaginal discharge and a mild, perivulvar dermatitis were present, but otherwise the vaginal conformation was normal. Complete neurological and musculoskeletal examinations were normal.

Differential diagnoses for the dog’s chronic vaginal discharge included perivulvar dermatitis leading to recurrent secondary vaginitis; urethral disease (e.g., granulomatous urethritis, neoplasia, etc.); a complicated urinary tract infection (UTI); and a congenital (e.g., vestibulovaginal stricture, vaginal septa, persistent hymen) or acquired genital disease (e.g., vaginal neoplasia, uterine stump pyometra, vaginal foreign body, vaginal polyp, primary infectious vaginitis). Brucellosis was considered a possible cause of both the stillborn puppy and the chronic vaginitis; however, the dog’s lack of systemic abnormalities were inconsistent with Brucellosis.

The initial diagnostic plan included a complete blood count (CBC), serum biochemical profile, urinalysis (collected during both micturition and cystocentesis for comparison), routine bacterial urine culture, abdominal radiography and ultrasonography, and digital vaginal and rectal examinations. Cystoscopy and vaginoscopy were planned if the preliminary tests failed to determine the underlying cause of the dog’s chronic vaginal discharge.

The CBC was unremarkable except for a mild erythrocytosis (hematocrit 0.584 L/L, reference interval 0.365 to 0.573 L/L; red blood cell [RBC] count 8.37 × 10¹² cells/L, reference interval 5.2 to 8.2 × 10¹² cells/L) and a mild lymphopenia (1.184 × 10⁹ cells/L; reference interval 1.2 to 5.0 × 10⁹ cells/L), which were attributed to mild hemoconcentration and stress, respectively. No abnormalities were present on the serum biochemical profile. A voided sample urinalysis revealed cloudy yellow urine, grossly visible mucous clots, a urine pH of 6, and a normal urine specific gravity (USG) of 1.040. On the chemstrip analysis, 1+ proteinuria, 3+ blood, and 1+ bilirubinuria were detected. On the sediment examination, evidence of pyuria (20 to 40 white blood cells [WBCs] per high-power field [HPF]), bacteriuria (scant rods and cocci), mucous strands, and microscopic hematuria (0 to 1 RBCs per HPF) were seen. Digital rectal and vaginal examinations were unremarkable except for the presence of the mild vaginal discharge. No vestibular or vestibulovaginal abnormalities were palpable. A urinalysis collected by cystocentesis was performed on day 2 to help localize the site of inflammation (genital versus urinary tract) and to permit aerobic culture of the urine to determine if either a primary or secondary bacterial UTI was present. The urine obtained by cystocentesis was slightly cloudy but dark yellow and well concentrated (USG 1.048). Trace protein and 1+ bilirubin were detected on the chemstrip analysis. Only rare WBCs and RBCs were detected per HPF on microscopic examination of the sediment. The aerobic urine culture was negative, which suggested the source of inflammation was the urethral or genital tract.

Abdominal radiographs revealed breed-specific spinal deformities and secondary spondylosis, and a curvilinear mineral opacity was seen just caudal to the neck of the bladder [Figure 1]. Differential diagnoses for the curvilinear mineral opacity included dystrophic mineralization of a uterine stump, a muscle belly, a benign or malignant tumor, and a radiopaque foreign body. No abnormalities were detected on abdominal ultrasonography, and the curvilinear object was not seen.

On day 3 of hospitalization, the dog underwent cystoscopy and vaginoscopy under general anesthesia. Urethroscopy and cystoscopy were performed first. A sterile, 18-cm, 2.7-mm diameter, rigid cystoscope^e was used. Sterile saline was used for infusion to allow adequate visualization. No grossly visible abnormal findings were present. Immediately following cystoscopy, vaginoscopy was performed using the same cystoscope as described above, as well as using a 103-cm, 5.9-mm diameter, flexible, human pediatric video-bronchoscope.^f No vestibular or vaginal deformities were identified; however, an off-white, curvilinear foreign object that was located just distal to the cervix was detected upon final inspection of the vagina. The foreign object was grasped using a rigid, 5-mm diameter, laparoscopic Allis tissue forcep fed into the vagina alongside the rigid cystoscope. Once the foreign body was removed, it was identified as a fragment of a fetal calvarium [Figure 2]. Although the vaginal wall adjacent to the foreign body did appear slightly contused and edematous, no evidence of prominent fibrous tissue was seen, and the cervix was easily visualized following removal of the foreign body. The vagina was lavaged with sterile saline following retrieval of the foreign body. The dog was administered a loading dose of meloxicam^g (0.2 mg/kg intramuscularly) postoperatively, and maintenance doses (0.1 mg/kg per os [PO]) were prescribed for an additional 3 days. The dog was also prescribed amoxicillin-clavulanic acid (22 mg/kg PO for 14 days) to help prevent a secondary iatrogenic infection from vaginoscopy.

More than 6 months after discharge, the dog continues to do well with complete resolution of the vaginal discharge. In addition, the owners reported an immediate improvement in the dog’s physical stamina. The dog no longer prefers to sit down and seems as energetic as she was prior to initial onset of clinical signs. We hypothesize that the sharp edges of the foreign body were causing the dog’s pain and discomfort when standing and moving.

Discussion

Chronic vaginitis leading to vaginal discharge is a relatively common problem encountered in both spayed and intact female dogs. In an ovariohysterectomized dog, chronic vaginitis can be caused by a number of different disorders [see Table], including a urogenital foreign body.^1–4 To our knowledge, only four other reports of vaginal foreign bodies in dogs have been published.^6–9 The foreign bodies that were removed from the other dogs included a piece of a lollipop stick,⁷ a disposable cigarette lighter,⁸ half of a ball-point pen,⁹ and a fragment of the calvarium of a macerated fetus.⁶ In the other case in which a fragment of fetal calvarium was removed, the dog initially presented for pollakiuria and hematuria.⁶ The time that had elapsed since whelping was not specified for the dog described by McCabe and Steffey.⁶ In the previously reported dog, the vaginal foreign body was visualized as a curvilinear, mineral opacity in the perineal region on abdominal radiographs, and, unlike in the case described herein, the calvarial remnant was palpable during digital vaginal examination.⁶ Further, in that previously reported case, an episiotomy was performed to surgically remove the dog’s retained fetal calvarium and repair an acquired band of fibrous tissue within the vestibule.⁶

In the other three dogs with vaginal foreign bodies reported in the literature, the duration of clinical signs (i.e., hemorrhagic vaginal discharge) prior to presentation varied from 21 days to 120 days, compared to almost 365 days in the case described herein.^7–9 The bizarre nature of the vaginal foreign bodies removed from the other three dogs suggests they were inserted by a person, likely a child. However, in all three cases, there was no known history of the foreign body being inserted.^7–9 In the two cases (including the case described herein) where the foreign body was a remnant of fetal calvarium, retention was likely related to either dystocia at the time of parturition, or premature fetal death in utero.⁶ For the case described herein, the calvarium was hypothesized to have belonged to either the stillborn puppy (if partially macerated) or perhaps an eighth puppy that was aborted late in gestation after the fetal skull had mineralized. If the latter event occurred, then the eighth puppy may have been missed on the initial radiograph (taken by the RDVM), and the rest of the puppy’s skeleton could have been expelled from the genital tract unnoticed along with either the fetal placentas following C-section or at a later date.

Although several cases have been reported of retained fetal tissues causing chronic vaginitis in large animals, the condition is still considered rare.^10,11 In animals, chronic retention of macerated fetal tissue is not usually associated with systemic illness, despite the presence of purulent material in the urogenital tract.^6,10,11 In contrast, acute retention of macerated fetal tissue often leads to systemic signs of illness and possibly even sepsis and death. Of the above-described four canine cases with vaginal foreign bodies, only one dog was systemically sick.⁸

In humans, vaginal foreign bodies are also uncommon, and the diagnosis can be very challenging. Fear, embarrassment, and denial may serve to delay the seeking and acceptance of treatment.^12–21 In addition, the majority of cases occur in young children who often do not remember inserting these objects.¹⁸ For that reason, vaginal foreign bodies can be retained for long periods of time (up to 20 years) before being diagnosed.^13–15,18 In one human study, the average duration of vaginal discharge prior to presentation was 13.7 months.¹³

Rare complications of chronic vaginal foreign bodies that have been reported in humans include a vesicovaginal or rectovaginal fistula, pelvic inflammatory disease, intrauterine synechiae, pelvic adhesions, and infertility.^12,14,20 More common complications of vaginal foreign bodies in humans include urinary incontinence, vaginal stenosis (that is indistinguishable from a congenital malformation), recurrent mucopurulent or hemorrhagic vaginitis, vestibulovaginitis, and vaginal lacerations.¹² Complications associated with vaginal foreign bodies reported in dogs include recurrent vaginitis, vaginal bleeding, and, in one of the documented cases, a fibrous band of tissue in the vagina, found and repaired surgically at the time of foreign body removal.^1–4,6 The fibrous band of tissue in the vagina was presumed to be a sequela of the inflammation associated with the presence of the foreign body (i.e., the fetal calvarium).⁶ Vaginal infections secondary to vaginal foreign bodies can be resistant to symptomatic and/or antibiotic treatment.^2–4 Conceivably, uterine fibrosis could result in infertility in intact bitches with long-standing vaginal foreign bodies; this sometimes occurs in cattle, horses, and humans.^3,4,10,20

Diagnosis of vaginal foreign bodies in dogs typically relies on one or more of the following: digital vaginal and rectal examination, plain and contrast radiographs (i.e., vaginogram), ultrasonography, and vaginoscopy. In some cases, more advanced imaging modalities including computed tomography (CT) or magnetic resonance imaging (MRI) for suspected nonmetallic foreign bodies may be required.^1–4,6–9 If the vaginal foreign body is not radiopaque (e.g., grass awns, wood pieces) or is deeply embedded in the vaginal wall, plain radiography and ultrasonography may fail to detect it, and more advanced imaging (e.g., MRI, CT) may be required for diagnosis. Advanced imaging may also be useful to plan for surgical removal of the foreign body and to repair any sequelae (e.g., a rectovaginal or vestibulovaginal fistula). Ultrasonography may contribute to the diagnosis and be useful for ruling out other differential diagnoses, such as ovarian or uterine neoplasia in intact bitches.^1–4

In humans, MRI has assisted in increasing the localization of nonmetallic vaginal foreign bodies missed by ultra-sonographic and radiographic studies; however, even MRI does not have a sensitivity of 100% for diagnosing vaginal foreign bodies.^13,14 Vaginoscopy is very useful for ruling out a vaginal defect resulting from the presence of a foreign body and for obtaining biopsies and vaginal cultures (bacterial and fungal). Vaginoscopy may also permit removal of the foreign body and vaginal lavage. Vaginal lavage may help resolve clinical signs more rapidly following foreign body removal. Because pain is associated with the presence of a vaginal foreign body, general anesthesia is recommended during vaginoscopy to allow a more thorough vaginoscopic examination as well as the possible nonsurgical removal of a foreign body.^1–4

Definitive treatment requires removal of the foreign body.^1–4,6–9 Foreign bodies located in the distal vagina or vestibule may be removed either manually or with forceps (with or without the aid of a speculum), or they may be flushed out using copious vaginal irrigation with dilute Betadine douches.^1–4,6–9 Removal of foreign bodies that are more craniad or that are embedded in the vaginal wall typically require vaginoscopic-guided retrieval or surgical extraction.^1–4,6–9

Conclusion

Vaginal foreign bodies are a rare cause of vaginal discharge in dogs, and they can be challenging to diagnose. Medical imaging and vaginoscopy are often required to confirm the diagnosis. As this case illustrates, retention of fetal tissues should be a differential diagnosis for recurrent or unresponsive vaginal discharge or hematuria in a bitch previously bred or in a breeding or ovariectomized bitch known to have had a previous litter of puppies. Treatment of vaginal foreign bodies requires surgical or endoscopic removal, and secondary complications (e.g., adhesions, uterine fibrosis, fistula formation) are rare even when the foreign body is longstanding.

Acknowledgments

The authors thank Dr. Klaas Post for his translation of the original 1989 article by Jacobs, et al, from Dutch into English.