Unilateral hydronephrosis and urosepsis secondary to vaginal ring pessary

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A 78‐year‐old woman presented to the emergency department via ambulance with a 3‐day history of increasing shortness of breath. On presentation, she was tachycardic, hypotensive and tachypnoeic. On further history, she denied dysuria, increased urinary frequency or changes with bowel habits. She did, however, report that her vaginal pessary had been falling out for the past 2 months. The vaginal pessary had been inserted 4 years prior to presentation, for vaginal prolapse.
A urine dipstick at the time of presentation revealed a cloudy, purulent sample with strongly positive leukocytes, blood and nitrates. Empirical antibiotic treatment for presumed urinary source sepsis was commenced in the form of gentamicin and ampicillin (urine culture returned positive for Klebsiella oxytoca).
Gynaecological examination revealed a vaginal ring pessary in situ that had malrotated and was unable to be removed due to partial adhesions of the anterior and posterior vaginal wall. Oestrogen cream (per vaginam) was commenced daily in an attempt to soften the adhesions. Further investigation with ultrasound revealed right hydronephrosis. Abdominal and pelvic computer tomography (CT) was obtained, which confirmed the right hydronephrosis with dilation of the right ureter to the level of the vesicoureteric junction. The pessary appeared to be the cause of the obstruction (Figs 1).
Cystoscopy and retrograde pyelography of the right collecting system revealed a tight extrinsic lower ureter stricture ‘corresponding to obstruction from the pessary’ and a 4.8‐Fr ureteric stent was placed under fluoroscopic guidance. The pessary was able to be removed with the aid of diathermy. After removal of the pessary, the right hydronephrosis and urosepsis resolved with the patient returning the baseline function.
This is the first case in reported literature of a malrotated vaginal ring pessary resulting in unilateral hydronephrosis. There are two previously reported cases in 1997 of unilateral hydronephrosis secondary to a neglected vaginal pessary,1 but this is the first case of malrotation while in situ, causing post‐renal obstruction. Both of these cases demonstrated good resolution after pessary removal, as was observed in this case.
Furthermore, there are well‐documented cases or urosepsis resulting from vaginal pessaries not associated with urinary tract obstruction.3 It is worth noting that both these cases reported ulceration secondary to local pressure effects. In these cases, the organisms responsible were Proteus mirabilis,1Staphylococcus aureus, Escherichia coli and group D Streptococcus.3 This poses the question of what empirical antibiotics should be if there is a known foreign body, such as a pessary.
Pessaries have a reported complication rate of approximately 56%,4 which the main complications include vaginal bleeding, vaginal discharge, extrusion of the device, discomfort, constipation or worsening urinary symptoms.4 In most cases of hydronephrosis, due to vaginal pessary, the patient had been lost to follow‐up after a period of several months to years prior to removal, further illustrating the importance of regular follow‐up to monitor for these complications. This case presents a unique complication that has not been previously reported in the literature and demonstrates the importance of ongoing specialist care and review. Patients with vaginal pessaries need regular follow‐up in view of the high rate of complications.
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