Vaginal foreign bodies are a common cause of vulvovaginitis in prepubertal girls.

Chronic irritation from the foreign body on the vaginal tissue can result in malodorous/purulent vaginal discharge and intermittent vaginal bleeding(eg, spotting).

| Epidemiology | • Usually prepubertal girls • Toilet paper most commonly retained object (ie, friable, white object) • Other objects include small toys and hair bands | | --- | --- | | Clinical features | • Vaginal spotting • Malodorous vaginal discharge • No signs of trauma (eg, lacerations) | | Diagnosis | • If suspected an external pelvic examination is performed with the patient in a knee-chest or frog-leg position→ | | Management | • Topical anesthetic & warmed fluid irrigation • If necessary, vaginoscopy under anesthesia |

Management depends on the ability to visualize the object, type of foreign body, and patient comfort.

• In the case of a small, easily visualized foreign body (eg, toilet paper) in a cooperative child, an attempt at removal (after application of topical anesthetic in the vaginal introitus) can be made using vaginal irrigation with warm fluid or a swab.
• In the case of a suspected foreign body that cannot be visualized or one that is large or associated with severe complications (eg, button battery causing burns), anesthesia is indicated for examination (eg, vaginoscopy [small-diameter endoscopy]) and foreign body removal. Patient anxiety, lack of cooperation, or very young age (generally age <5) may also prohibit adequate clinical evaluation, warranting examination under anesthesia.

<aside> 💡 Speculum examination should not be performed in a prepubertal girl.  It can result in significant discomfort and trauma due to the narrow vaginal introitus and sensitive hymenal tissue from a low estrogen level at this age.  Even when under anesthesia, prepubertal girls should be evaluated with vaginoscopy, not speculum examination.

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Child protective services should be contacted when child abuse or neglect is suspected, and a vaginal foreign body can be the initial presentation of sexual abuse. However, the presence of what is likely toilet paper does not immediately raise concern for abuse, particularly in an otherwise asymptomatic patient (eg, no behavior changes, no signs of vulvar trauma) whose mother sought medical care on the first day of symptom onset.

• EDUCATIONAL OBJECTIVE