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Abdominal pain with a difference: a case study

Janet Webb
BSc(Hons) RGN DipN(Lond)
Practice Nurse
Lindum Medical Practice
Lincoln

The abdominal pain had started several months ago. At first Tracey thought it was food poisoning - she had been to a party and drunk far too much alcohol and eaten barbecue food, then had vomited several times the next day. She could not really pinpoint the start of the vaginal discharge, other than that it had started some time after the pain. Her menstrual periods had been regular throughout, and no different in flow or amount, but were becoming increasingly painful each month. Sexual intercourse had become impossible due to the pain, and the increasing amount and odour of the discharge had prevented either partner really wanting to initiate it. She was not taking any medication other than the oral contraceptive pill. There were no other symptoms and no previous history of note.
Tracey had attended the surgery three months earlier with the same pain. She had then been menstruating, but her urine had shown leukocytes so she was treated with trimethoprim for a urinary tract infection. The doctor had advised her to come back for a high vaginal swab when her period finished, but she had not returned. By then the vaginal discharge was increasingly foul smelling and her vagina increasingly sore, and she admitted to having felt embarrassed and rather reluctant to undergo an internal examination. She had treated herself with thrush cream from the chemist instead, but the symptoms continued with increasing severity.
Tracey was now feeling so ill that she was willing to have any examination at all, she said. She was hardly eating since defecation was so uncomfortable. She had been unable to go to work for nearly three weeks, was hardly sleeping, and felt incapable of thinking of anything but the pain and the odour of her discharge.
I asked her for a sample of urine, which again showed leukocytes, and also protein. I went on to examine her abdomen. She was tender all over, but much worse in the left lower quadrant, where there was guarding and seemed to be a dull mass, but given her history this could have been faecal, as it felt quite deep.
She agreed to a speculum examination of the vagina. The labia were quite sore, and the thick light brown vaginal discharge was very strongly malodorous. I proceeded carefully and slowly inserted a slim speculum, then opened it to reveal what looked at first like a large fibroid - a glimpse of smooth red surface among the thick discharge at the end of the speculum. The surface looked hard, however, and somehow not quite right for a fibroid. Very carefully, and with Tracey's brave agreement, I opened the speculum slightly wider. Not only did the red object appear to be plastic but I could now see a scalloped pattern on its surface. I asked Tracey tentatively if there was anything in her vagina. She said no, she had not been able to tolerate tampons. She asked what I meant. I told her I could see something but would need a better look. If she could bear with me I'd get another instrument and would be as gentle as I could. She agreed that at this stage anything was worth a try. With a sponge-holder I moved the thick discharge and found that I could grip the object. It was too big to remove through the speculum but I gradually brought it out behind the speculum. The smell was almost overwhelming. Tracy initially cried out then felt instant relief as the object and instruments were brought out. It was easily identifiable as the adjustable head of a garden hosepipe. It had been lying across her vaginal vault, slightly more to the left side; it measured 5.5cm × 3cm. There was no bleeding.
Tracey's expression turned from relief to amazement to mortification. "How did that get there?" she asked. I couldn't answer. I looked at her, then we both laughed at the absurdity of the situation. I felt like a magician. Tracey wiped herself then jumped down easily from the couch. When I returned she looked awkward, clutching her bag as if to leave. She sat down again at my invitation.
It seemed that the party had been at her friend's instigation, to "celebrate" Tracey's temporary separation from her husband. There had been lots of people there, most of whom she did not know. She had not intended to stay the night but had become so drunk that it was impossible to do anything else, and had no recollection of where she had slept. She had reunited with her husband soon after, and he was now very concerned about her health. She felt she could not tell him the cause of her symptoms, saying he would "go berserk".
I suggested a genitourinary clinic appointment, since we could not be sure whether sexual intercourse had taken place; indeed, she had no idea what had happened to her. She would consider it. I prescribed metronidazole for bacterial vaginosis and arranged to see her again the following week.
To say the outcome had taken me by surprise was a massive understatement. I had considered pelvic inflammatory disease, bacterial vaginosis, endometriosis, pelvic cyst and urinary tract infection while listening to her history, but nothing encompassed all the symptoms in the timescale involved.
I began to consider the implications. Tracey might have been infected with a sexually transmitted disease or HIV. I wondered about the people who could have done this and whether it had been simply a party that became out of control or a malicious attack. Since she had no idea who most of her fellow partygoers were, she had discounted any follow-up. I had suggested contacting the police, but she had strongly disagreed with this. She had said there would be little point in asking her friend who the other people were, as she had no intention of telling her friend what had happened. I wondered what she would tell her husband, to explain the miraculous cure of her pain.
Tracey returned a week later. The swab had confirmed a heavy growth of anaerobes and that metronidazole had been the correct prescription. Vaginal examination showed no evidence of any remaining trauma, there was some residual vulval soreness, but other than that she was well. She had not gone to the GU clinic. She had told her husband "everything". He had, she said, wanted to kill whoever had done this, but in the end blamed himself for leaving her vulnerable to such people. Strangely, the outcome was that they were closer now.