Maddy is 15. She presents with a one week history of a brown smelly discharge from the vagina. Her period ended eight days ago. At first, she thought it was just some spotting tailing off but now it’s heavier and smelly. Maddy is a gymnast and swimmer and has used tampons since she started her periods at 13. She has never been sexually active. Shyly, she admits that she “felt up inside” herself and thinks there might be a tampon up there. She’s not sure she removed the last one at the end of her last period, but she’s scared by the discharge and has come to see you for help.
Retained tampons are a common presentation to the emergency department and to GPs. Most GPs will tell you that the first retained tampon case they encounter is a rite of passage into the “real world of GP” and is usually a learning experience.
Here are some top tips for your first time
- May or may not remember having “forgotten” a tampon
- Foul smelling PV discharge, often watery and brownish
- Usually well but embarrassed however don’t forget the risk of Toxic Shock Syndrome (TSS) – you will need to check observations/sepsis criteria and if scoring high consider this within your differential
Top Tips for Managing
There are no official published guidelines….
Management consensus from a group of GPs nationally:
- Firstly encourage her to try and remove it herself by bearing down on the toilet slightly and using her fingers to grasp either the string or the tampon itself.
- Have a look with a speculum +/- a bimanual exam (preferably in someone else’s room because the smell will linger).
- Pull it down (with sponge-holding forceps) to where she can reach herself and send her to the toilet to remove and dispose of it.
- If you must remove yourself have a specimen pot half full of water to put in in and shut the lid immediately.
- It may be sensible to check that there are no more up there, especially if the patient reports that this has happened before, or if she tells you she habitually uses more than one tampon at a time. This is not advisable or safe, but sadly not uncommon especially in adults with menorrhagia.
In the context of the emergency department and Maddy:
- Reassurance is key – she is embarrassed. If you are embarrassed too this is only going to end badly.
- Reassure her that exploring her own body, including her vagina is completely normal.
- Remind her that the string is sewn through the tampon so it is unlikely to have fallen off. Feeling inside for it and pulling it down is likely to be effective.
- Encourage her to go to the patient toilet in private and to try to bear down and pull on whatever is up there to get it out. Lots of teenagers are embarrassed and ashamed to have touched their own vulva or vagina. Understanding that this is okay may be all you need to give her the confidence to solve her own problem.
- If this is unsuccessful and you need to examine her and intervene, make sure you have all the kit you need. In some departments this may mean you have to refer to Gynae for them so it’s worth knowing what they will do.
What you need
- A chaperone/assistant
- A room with a lockable door
- Disposable gloves
- Speculum – probably a small/”virgin” size for Maddy
- Lubricating jelly
- A specimen pot, half full of water
- Sponge-holding forceps
- A decent light source
What to do
- Examine externally first. If the tampon is just inside the vagina you may well see it and be able to easily remove it.
- Pass the speculum and have a look – if you see the tampon then grasp it with sponge-holding forceps, pull it out and put it straight into a specimen pot with water in and dispose.
- If you insert the speculum and cannot see the tampon but can see the cervix clearly it is probably worth pulling back slightly and reinserting to ensure you visualise the posterior fornix too.
- If she is unable to tolerate opening the speculum blades a gentle bimanual examination may allow you to feel the tampon and grasp it between your fingers to remove it.
Provided she is well and her observations are normal, she does not need antibiotics or any follow up other than reassurance and safety netting. If she is sexually active and/or the discharge is profuse or typical you may wish to consider swabs. If she has symptoms of TSS or Pelvic Inflammatory Disease you need to manage as per these conditions.
Maddy and her mum disappear to the toilet in the department. They return 10 minutes later. Maddy is tearful and says the tampon is definitely there but she’s too scared to pull it down. She says it feels really low down and uncomfortable. You take her to a quiet lockable room with one of the nurses and the kit list above. Explaining carefully what you are going to do you examine her vulva externally and can see the tampon just inside her vagina. You use some forceps to remove it, and having been well-educated by this article you put it straight into a pot of water and shut the lid tightly. You chat about whether there is a possibility there might be another tampon up there and Maddy assures you that this is not possible. You discharge her from the department, relieved, with some safety netting advice about remembering to remove future tampons and to come back if the discharge persists or if she becomes unwell.
As an adult (and nurse) who had this happen a few years ago, it’s humiliating. I had had 3 children, I was well used to people down that end and I knew something must be wrong from the truly foul discharge. However, I genuinely could not remember not removing a tampon, and after many private attempts could not find any string or anything anywhere,. Turns out it had lodged sideways right up my cervix with the string wrapped round it. I was glad to have discreet a GP, who agreed to see me urgently after my panicked phone call. I ended up with PID and felt very, very unwell especially after I started the antibiotics after the tampon was finally retrieved. I am still extremely nervous about using tampons occasionally now, but sometimes needs must.
Nitrous isn’t anything I’d considered as I’m a GP and only have low tech interventions like as we call it the “vocal local”. Sounds like a great tip though. I’d love to know what other people think as an option.
Definitely think this is a great opportunity to teach teenagers (and to be fair adults too) not to be afraid of their bodies.
Great tips. I see this as an opportunity to empower young women to really educate themselves about their bodies, planting the seed of regular cervical screening, and generally turning the consultation into a positive experience. Sometimes a little bit of nitrous makes the retrieval less traumatic for very anxious and fearful teens