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- Hematuria
- Urinary and genital tract disorders
- Medical education
- Healthcare improvement and patient safety
Description
Vaginal pessaries represent a valid therapeutic option for the management of female pelvic organ prolapse in elderly women with significant comorbidities. Although leading to good functional and quality of life outcomes, when neglected, they can cause significant and severe complications.1
An 87-year-old woman semidependent and uncooperative due to progressive Alzheimer’s dementia, who has lived in a nursing home for the last 5 years, presented to our outpatient clinic for ‘intermittent hematuria’. She carried a pelvic ultrasound documenting a ‘polypoid formation with 23 mm on the posterior bladder wall suggesting a bladder tumour’.
The blood loss had been detected intermittently in the diaper that she uses for hygienic purposes.
There were no analytical abnormalities except for leucoerythrocyturia with positive Escherichia coli urine culture. The hypothesis of a urothelial lesion led to the scheduling of a cystoscopy under anaesthesia and an abdominopelvic CT scan.
The abdominopelvic CT scan documented ‘a hyper dense linear formation, superior to the vaginal dome’ (figure 1). After observing the images, we suspected an intravaginal foreign body and performed the coronal CT scan reconstruction. The hyperdense retrovesical formation corresponds to an intravaginal ring shaped structure, consistent with a pessary (figure 2).
CT scan—within the pelvic cavity we observe a bladder with smooth and regular wall and in retrovesical position and next to the vaginal dome a hyperdense formation.
Coronal CT reconstruction—the hyperdense retrovesical formation corresponds to an intravaginal ring shaped structure consistent with a pessary.
We performed the cystoscopy under anaesthesia and saw a globally inflammatory bladder with a bulbous pattern, but without tumour lesions. A bladder biopsy revealed erosive cystitis.
The procedure was completed with a vaginal examination that confirmed the presence of a pessary intimately adhering to the vaginal wall with an intense inflammatory reaction. Its removal triggered abundant vaginal bleeding.
It was not possible to determine the date of placement of the neglected vaginal pessary. Neither the nursing home nor her family members had knowledge of the condition (no information on her individual file).
The patient is well, without macroscopic blood loss, although with persistent asymptomatic bacteriuria.
Learning points
This case report emphasises that in the setting of signs or symptoms of a genitourinary disorder, a meticulous physical and pelvic examination should always be performed before the request of any medical exams.
Neglected medical devices can cause potentially severe complications, and lead to unnecessary appointments as well as invasive procedures, and carry high medical costs.1
This case report highlights the indispensability of good medical registries within the personal clinical file, and reinforces the need for an electronic department registry that enables clinicians to accurately recall these patients.2
Footnotes
Contributors JCR was the attending urologist, the author of the manuscript, and collected and reviewed the data.
CL performed the CT scan and review the manuscript.
Competing interests None declared.
Patient consent Consent obtained from guardian.
Provenance and peer review Not commissioned; externally peer reviewed.