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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 32-35

Palm fronds and animal jaw in the vagina mimicking advanced cancer of the cervix


1 Department of Obstetrics and Gynaecology, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Web Publication20-Jun-2018

Correspondence Address:
Dr. Aisha Mustapha
Department of Obstetrics and Gynaecology, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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DOI: 10.4103/ssajm.ssajm_11_17

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  Abstract 


Herbal intravaginal medications are not uncommon in northern Nigeria, often used as aphrodisiacs or less commonly, to treat infective gynaecological conditions. Most of these medications are self-inserted. We report an unusual case of a 20-year-old patient with sickle cell disease with primary infertility who was referred from a general hospital with both clinical and radiologic evidence of advanced cancer of the cervix, for expert management. Speculum examination revealed copious dark frothy malodorous vaginal discharge with a huge necrotic irregular cervical mass extending to the upper two third of the vagina. Digital pelvic examination performed to clinically stage the tumor revealed the mass was made up of organized palm fronds and animal jaw, which were probably inserted for the patient 2 months ago as a therapy for primary infertility. The herbs were evacuated to reveal ulcer craters on the cervix, which bled on contact. Patient responded to antibiotic therapy and is being followed up in our clinic for the primary infertility.

Keywords: Advanced cancer of the cervix, foreign body, herbs, vagina


How to cite this article:
Mustapha A, Olajide OM, Aliyu RM, Kolawole BO. Palm fronds and animal jaw in the vagina mimicking advanced cancer of the cervix. Sub-Saharan Afr J Med 2018;5:32-5

How to cite this URL:
Mustapha A, Olajide OM, Aliyu RM, Kolawole BO. Palm fronds and animal jaw in the vagina mimicking advanced cancer of the cervix. Sub-Saharan Afr J Med [serial online] 2018 [cited 2019 Oct 17];5:32-5. Available from: http://www.ssajm.org/text.asp?2018/5/1/32/234754




  Introduction Top


Bizarre objects have been found in the vagina.[1] Over a hundred years ago, authors have reported foreign bodies inserted into the vagina and cervix uteri as a means of contraception.[2] Some women insert these foreign bodies for sexual gratification, reduction of a prolapse or as therapy for various infective gynaecologic conditions. In northern Nigeria however, most are herbal vaginal insertions used as aphrodisiacs. However, there has been no reported case of these insertions used as the treatment of primary infertility in northern Nigeria. Most of these medications are self-inserted. These insertions have caused various havoc ranging from rectovaginal and vesicovaginal fistulae, chronic vaginal discharge, and cervical mass mimicking advanced cancer of the cervix.[3] We report a case of a 20-year-old primarily infertile sickler, who presented with features of advanced cancer of the cervix and was managed in the gynaecologic unit of Ahmadu Bello University Teaching Hospital, Zaria in September, 2015.


  Case history Top


She was a 20-year-old known sickler, referred to our gyne-oncology clinic from a general hospital in Kano State with both clinical and radiological (ultrasound) features of advanced cancer of the cervix, for biopsy, histology, and further management. She was a married nullipara, primarily infertile for 2 years, who presented with a 2-month history of lower abdominal pain and abnormal vaginal discharge. The lower abdominal pain was dull, non-radiating with no aggravating or relieving factors. The discharge was copious, brown, frothy, and foulsmelling with occasional passage of necrotic tissue and altered blood. She also had deep dyspareunia and occasional post coital bleeding. Last coitus was 2 days prior to presentation. She had no urinary, gastrointestinal, cardiopulmonary or central nervous system symptoms. However, she never sought orthodox treatment for her infertility. Coitarche was at marriage, 2 years ago but she could not remember her age at menarche. She had not used contraceptives in the past, and she was not aware of  Pap smear More Details as a screening procedure for cervical cancer. She was diagnosed with sickle cell disease as a child, had two other siblings with the condition, but she did not attend sickle cell clinic and was not on routine drugs. She was unsure of her genotype but had approximately four mild crises per year, not requiring hospital admissions. She was not a known diabetic or hypertensive and had no known drug allergies. She was the only wife of a 33 year-old trader, in a monogamous non-consanguinuous setting.

Examination revealed sickle cell habitus and normal vital signs. The abdomen was flat with no areas of tenderness, no palpable organomegaly or abdominopelvic mass. Pelvic examination revealed a wet vulva, stained with an intensely putrid and foul smelling blood stained discharge in the vagina, typical of advanced cancer of the cervix. Gentle speculum examination (which could not be completely inserted) revealed necrotic tissue at the upper third of the vagina including the fornices. Digital examination revealed multiple ragged wood-like foreign bodies felt occluding the entire upper two-thirds of the vagina. Palm fronds and animal jaw were evacuated from the fornices of the vagina and the ectocervix [[Figure 1] and [Figure 2]]. They were rinsed in a kidney dish of water and on immersion, produced a frothy fluid [Figure 3].
Figure 1: The foreign body, freshly removed

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Figure 2: The foreign body (palm fronds and part of animal jaw), after washing

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Figure 3: Frothy fluid just discarded from kidney dish

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Diagnosis was chronic cervicitis and vaginitis secondary to foreign body insertion, in a patient with primarily infertile sickle cell disease. Following evacuation, the cervix had multiple hemorrhagic ulcers with vaginal abrasions [Figure 4]. High vaginal and endocervical swabs were taken. Toileting was performed via irrigation with dilute chlorhexidine solution. Patient was counseled, and further history was sought regarding the removed foreign body, but she denied any accidental or intentional insertion of any foreign body into the vagina. She, however, admitted that she went to seek help for infertility from a traditional healer, but she could not remember whether the insertion was part of the treatment process.
Figure 4: Multiple hemorrhagic areas on the cervix

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She was commenced on empiric broad spectrum triple antibiotic therapy (ciprofloxacin, gentamicin, and metronidazole) while awaiting sensitivity results. She was also commenced on hematinics and proguanil tablets. Her packed cell volume was 23%, and she was asymptomatic, likely her steady state.

Two weeks later, when she presented for follow-up, the vaginal discharge had stopped. The repeat ultrasound showed an anteverted uterus with anteroposterior diameter of 3 cm, with normal myometrial echotexture and endometrial echoplate. The cervix was 2.5 cm long with no masses seen. The adnexa, urinary bladder, and pouch of Douglas (recto-uterine pouch) are unremarkable. Endocervical swab result retrieved cultured Klebsiella species sensitive to gentamicin. She had completed a 7-day course of gentamicin injection 80 mg 8 hourly. Her genotype was HbSS. Full blood count was essentially normal apart from moderate anemia of 26.5 L/L and sickle cells on blood film. Retroviral screening was non-reactive. Pap smear revealed chronic inflammation with no evidence of dysplasia or malignancy. She was continued on hematinics, malaria prophylaxis, and antibiotics.

Following adequate counseling, she was referred to the infertility unit with her husband and also to the hematology day-care for enrolment into the sickle cell clinic.


  Discussion Top


An extraordinary variety of foreign bodies may be found in the vagina, including safety pins, hair grips, pencils, small jam jars and toilet tissues, especially in the mentally retarded or the young child.[1] Documented cases of foreign body insertions into the vagina date back to over a hundred years ago.[2] Other bizarre objects found in the vagina as reported in previous literature include metal bangles used as pessary,[4] cover of a shampoo bottle,[3] and ferrule with an eraser of a pencil.[5] In adults, these objects are mostly inserted for spiritual, traditional, sexual, therapeutic, or contraceptive purposes. Therapeutic reasons reported in the literature include treatment of infertility,[6] "melting" of fibroids.[7] In our patient, however, the palm fronds and animal jaw found in the lower genital tract were probably for therapeutic reasons. Such incidents have not been reported before, in northern Nigeria. Denial of such insertions is common[3],[8],[9] as was the case in the index patient.

The symptoms caused by foreign bodies depend on the type, chemical composition, shape, and duration since insertion in the vagina. The most common symptoms are lower abdominal pain, copious foul smelling vaginal discharge, bleeding, and dyspareunia;[3] all of which were present in our patient. Long standing vaginal foreign body results in chronic inflammation and tissue ischemic necrosis, which can lead to perforation of the affected region. This can lead to vesicovaginal fistula and urinary incontinence as well.[7],[8],[9],[10],[11] Ulceration of the surrounding tissues, peritonitis, and migration of the foreign body to other cavities have been reported as well.[10] It may be complicated by vaginal stenosis or near complete obstruction.[7] Fortunately, our patient did not have any of these complications, probably because of early presentation and prompt referral.

Few authors have reported intravaginal foreign body mimicking advanced cancer of the cervix,[3],[10] but not similar to what was found in this case.

This case emphasizes the need for attending physicians to take detailed history and do a speculum examination for all cases of chronic vaginal discharge before requesting for an ultrasound. This is because in this case, the ultrasound picked the foreign body as a huge cervical mass, which will have been ruled out by a speculum examination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pokorny SF. Long term intra-vaginal presence of foreign body in children. A preliminary study. J Reprod Med 1994;39:931-5.  Back to cited text no. 1
[PUBMED]    
2.
Heineck AP. Removal of a foreign body introduced into the uterine cervical canal to prevent conception. JAMA 1913;61:868.  Back to cited text no. 2
    
3.
Michał C, Aneta SJ, Witold L, Grzegorz J. Vaginal foreign body mimicking cervical cancer in postmenopausal woman − Case study. Prz Menopauzalny 2015;14:208-10.  Back to cited text no. 3
    
4.
Dasari P, Sagili H. Incarcerated foreign body in the vagina − A metal bangle used as a pessary. BMJ Case Rep 2012;2012:bcr0120125596.  Back to cited text no. 4
[PUBMED]    
5.
Hassan SA, Majd AS. Neglected intra-cervical bizarre foreign object. Saudi Med J 2012;33:1343-5.  Back to cited text no. 5
    
6.
Sagorika P, Vishwajeet S, Rahul JS, Arvind K. Vesicovaginal fistula due to vaginal herb for primary infertility: Could it be devastating? BMJ Case Rep 2013; 2013:bcr2013200563.  Back to cited text no. 6
    
7.
Adaji SE, Bature SB, Shittu OS. Vaginally inserted herbs causing vesico-vaginal fistula and vaginal stenosis. Int Urogynecol J 2012;24:1057-8.  Back to cited text no. 7
[PUBMED]    
8.
Biswas A, Das HS. An unusual foreign body in the vagina producing vesicovaginal fistula. Indian Med Assoc 2002;100:257-9.  Back to cited text no. 8
    
9.
Picurelli L, Lopez Olmos J, Sendra A. Vesicovaginal fistula caused by foreign body in the vagina. Actas Urol Esp 1997;21:511-2.  Back to cited text no. 9
    
10.
Oguntayo OA, Zayyan M, Odogwu K, Koledade AK, Mbibu H, Bello A et al. Foreign body (metallic flashlight cover) in the urinary bladder mimicking advanced cancer of the cervix: Case report and review of literature. Afr J Urol 2009;15:111-3.  Back to cited text no. 10
    
11.
Igberase GO, Gharoro EP, Ebeigbe PN, Mabiaku T. Vesicovaginal fistula following insertion of herbs in the vagina by a traditional medical practitioner in the Niger delta of Nigeria. J Obstet Gynecol 2009;24:356-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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