It came out of a vagina -- what is it?

[baya]

It measures more than an inch long, about half an inch wide, and is a couple millimeters thick. It is thickest in the center. The shape is vaguely oval, but irregular and assymetric. The edges have a wispy appearance.

The center (where it's thickest) is light brown. The edges are pale yellow.

It's soft - blendable, pliable, and strechable.

It has elastic properties - it can be stretched, but will consistently return to it's original shape.

Patient reports removing it manually in the shower without pain.

The patient has a history of pain during vaginal intercourse and during pelvic exams. Regular paps, no history of any STD.

So - what is it? Any ideas?

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[neilc]

what does she say when you ask her what she put up there?

 

[baya]

what does she say when you ask her what she put up there?

I asked her about recent sexual activities, inserting objects into her vagina, etc., and got all negatives -- claims nothing has entered her vagina in the last 6 months other than a speculum and her own finger.

 

[moni1999]

Could it be an old tampon?

 

[fedor]

At first i thought you were posting a Tolkienesque riddle for our amusement.

Do you have a picture of it?

What's the history on the patient?

 

[baya]

Could it be an old tampon?

Hmm. I don't think so. Nothing cottony about it.

 

[Flea girl]

LMP was how long ago?

 

[baya]

At first i thought you were posting a Tolkienesque riddle for our amusement.

Do you have a picture of it?

What's the history on the patient?

Sorry, it's a real-life riddle (although I am Tolkien fan).
Image is attached.

Hx: 27 yo female, on depo, long standing dysparenuria, no other pelvic symptoms.

 

[RossFamily]

hubby thinks it's an old condom.....I say diaphram??

 

[RossFamily]

okay, just saw the picture hubby says embryo

 

[baya]

LMP was how long ago?

She's on depo, and didn't remember her last true menstruation.
Says she last spotted on July 4th of this year.

Also reports no vaginal intercourse for the last 6 months.

 

[fedor]

She's on depo, and didn't remember her last true menstruation.
Says she last spotted on July 4th of this year.

Also reports no vaginal intercourse for the last 6 months.

Do you believe her?

 

[baya]

Do you believe her?

Yeah, I do. We had a (relatively) long talk about it.

 

[RossFamily]

Yeah, I do. We had a (relatively) long talk about it.

How about a blighted ovum?

 

[baya]

How about a blighted ovum?

Wouldn't a blighted ovum have passed sooner than 6 months after her last vaginal intercourse?

 

[RossFamily]

Wouldn't a blighted ovum have passed sooner than 6 months after her last vaginal intercourse?

That's about all I have for guesses. I had two OB's here look at it and not know what it was. Any more hints?

Hubby

 

[fedor]

Did you send it to path?

 

[fantasty]

Any physical exam findings?

 

[Poety]

Could that be a piece of a dildo? Has she engaged in penetration with sex toys? If shes having dysparaneuria, isn't she having some kind of sex then? BUt she said last sex was 6 mos ago?


If not the above, i say condom (stretchy, returns to shape, etc etc), or penile ring that her partner may have worn that slipped off, I think those are stretchy too to fit over the erect penis.

YOU'VE GOT TO KEEP US POSTED!

 

[baya]

Could that be a piece of a dildo? Has she engaged in penetration with sex toys? If shes having dysparaneuria, isn't she having some kind of sex then? BUt she said last sex was 6 mos ago?

If not the above, i say condom (stretchy, returns to shape, etc etc), or penile ring that her partner may have worn that slipped off, I think those are stretchy too to fit over the erect penis.

YOU'VE GOT TO KEEP US POSTED!

Patient says she does not use penetrative sex toys (because they hurt too). Dysparaneuria is long standing (10 years). Stopped having sex (although she still has a boyfriend) due to the pain. Since we have been unable to find a medical cause, she is attempting to address it with a psycotherapist.

It really doesn't look like a foreign object to me. It looks like tissue.

 

[RossFamily]

Does this mean that you dont even know what this is? Was it examined histologically? If so, what did you see?

 

[fedor]

Do you still have the sample in your possession?

 

[Poety]

Oh its tissue - WEIRD! I'm totally fascinated and grossed out too HAHAHAHAHAHA

Then I'm going with the other posters and saying some kind of embryo- could it be a cyst? I know that would be weird, but whatever that is is weird ~

You guys MUST have sent that to path, when does the report come in?

edit: that couldn't be from endometriosis could it? Or an endometrioma? Im just going with dysparaneuria/possibly 2^ adhesions or scarring/ etc etc


fascinating stuff... really

edit: looked at picture again, Im going with chocolate cyst that got partly adsorbed in the vagina thats it.. thats my final guess

 

[baya]

Oh its tissue - WEIRD! I'm totally fascinated and grossed out too HAHAHAHAHAHA

Then I'm going with the other posters and saying some kind of embryo- could it be a cyst? I know that would be weird, but whatever that is is weird ~

You guys MUST have sent that to path, when does the report come in?

edit: that couldn't be from endometriosis could it? Or an endometrioma? Im just going with dysparaneuria/possibly 2^ adhesions or scarring/ etc etc


fascinating stuff... really

edit: looked at picture again, Im going with chocolate cyst that got partly adsorbed in the vagina thats it.. thats my final guess

Well, I'm just the second year medical student who interviewed the patient, and the attending didn't think it was worth investigating, so it didn't make it to path.

She tested negative on blood work for endometriosis (although I guess that's not conclusive).

I'm just really curious, and thought I'd see what more experienced medical minds had to say about it.

I guess a cyst is possible, but I'd be suprised to see one spontaneously make its way to the vagina like this.

 

[cloud9]

Well, I'm just the second year medical student who interviewed the patient, and the attending didn't think it was worth investigating, so it didn't make it to path.

She tested negative on blood work for endometriosis (although I guess that's not conclusive).

I'm just really curious, and thought I'd see what more experienced medical minds had to say about it.

I guess a cyst is possible, but I'd be suprised to see one spontaneously make its way to the vagina like this.

If the attending didn't feel it worth investigating then I would think he/she has some idea of what it is. Did you ask? The attending should have sent it for investigation to ensure it was NOT neoplastic.

I hope it wasn't just a cavalier attitude that led to its disposable.

I'm thinking sex toy and the attending may have not felt entirely comfortable with the subject (of sex toys).

 

[Idiopathic]

the attending didn't think it was worth investigating, so it didn't make it to path.

Are you kidding me? I would actually like to call this patient's lawyers for her, to save her the trouble.

 

[baya]

Are you kidding me? I would actually like to call this patient's lawyers for her, to save her the trouble.

I agree one hundred percent that it should have been sent to path.

On the upside, the patient recently had a pap (the results of which are not back yet).

 

[baya]

Do you still have the sample in your possession?

Yes, I do, although it's starting to deteriorate. It was originally in water, which I think was lysing cells. It's now in rubbing alcohol, that being the only vaguely preserving liquid I've got. Putting it into alcohol significantly changed it's appearance. I could take another picture, if you like.

If medical students at my school still had microscopes, I would have looked at it by now, but they don't.

 

[baya]

Any physical exam findings?

No. Only thing of any interest at all was her transvaginal ultrasound (last year, while trying to find cause of dysparaneuria) showed her left ovary to be very lateral.

 

[Poety]

You could take that sample into your lab or into the obgyn floor and look at it under microscope - what happened to the color of it when you put it in fluid?

I'm still going with chocolate cyst - as I said before FINAL ANSWER - if she has some anomolies of her anatomy as well, perhaps she is shedding into the apex of the vagina for whatever reason

TAKE ANOTHER PICTURE! on a white bakcground please?

 

[cytoskelement]

Wait a sec! You're the MS II that interviewed the patient and then took the said "questionable" vaginal object home with you to preserve it. Does anyone else think this is rather strange?

 

[fedor]

Wait a sec! You're the MS II that interviewed the patient and then took the said "questionable" vaginal object home with you to preserve it. Does anyone else think this is rather strange?

Of course it's strange. From the beginning I assumed it was her own specimen -- not a patient's.

That doesn't mean we can't help with the diagnosis.

 

[Pretty POHA]

Wow. I'm visiting the OB/GYN Forum more frequently. This thread is far more interesting than the ones you find elsewhere!

 

[Poety]

Wow. I'm visiting the OB/GYN Forum more frequently. This thread is far more interesting than the ones you find elsewhere!

I thought you were going into psych asher? haha obgyn is FASCINATING isn't it?

 

[baya]

TAKE ANOTHER PICTURE! on a white bakcground please?

Here's another picture.

 

[Poety]

Here's another picture.

THATS DISGUSTING

I'm sticking with chocolate cyst - it does look like tissue. Send that to path and have them analyze it, maybe its some kind of decidual cast or something, I dunno - but its disgusting, do you have that thing hanging around your room? Go wash your hands for Petes sake and thanks for that pic!

ok i looked again and the middle looks like it had some kind of blood supply to it, like right in the middle - i really think that needs to go to path

 

[fedor]

Another pic with much better light, please.

 

[baya]

Another pic with much better light, please.

Are these any better?

 

[chicamedica]

Are these any better?

does that second pic. . .have LEGS??

 

[Poety]

does that second pic. . .have LEGS??

OMG IS THAT A FETUS? <FAINT>

 

[tiredmom]

What did her cervix and vagina look like on the spec exam? Excoriated? Closed or open os? How's the pain now that it's out?

 

[RossFamily]

My final guess after having done much reading is that this is more than likely a pedunculated endometrial polyp that simply sloughed off likely having outgrown it's blood supply. The appearance is grossly benign looking and probably why the doctor didn't feel the need to send it to pathology.

Hubby

 

[Poety]

this is also being followed on the path forum, they have some interesting things to add as well, however I agree with the idea that only the fibromas seem to look so rubbery like that - are the pedunculated polyps rubbery?

And how did baya get to take this specimen home? thats just odd - did you ask permission of the patient?

 

[Stinger86]

Gummy bear

 

[RyMcQ]

Well, I'm just the second year medical student who interviewed the patient, and the attending didn't think it was worth investigating, so it didn't make it to path.

Remind me not to send my wife to your hospital.

 

[DropkickMurphy]

Wow. I'm visiting the OB/GYN Forum more frequently. This thread is far more interesting than the ones you find elsewhere!

No kidding, this beats the hell out of the 15 or so "What would you do if docs only made ______________ dollars per year?" threads in other forums. By the way, OB/GYN is the one rotation in med school I am not looking forward to and that I plan to slack off during.

 

[baya]

My final guess after having done much reading is that this is more than likely a pedunculated endometrial polyp that simply sloughed off likely having outgrown it's blood supply. The appearance is grossly benign looking and probably why the doctor didn't feel the need to send it to pathology.

Hubby

Okay, thanks.
Since I haven't studied this stuff yet, can you tell me if that's fully compatible with the patient's story - i.e. no pain or blood associated with it?

 

[LADoc00]

It measures more than an inch long, about half an inch wide, and is a couple millimeters thick. It is thickest in the center. The shape is vaguely oval, but irregular and assymetric. The edges have a wispy appearance.

The center (where it's thickest) is light brown. The edges are pale yellow.

It's soft - blendable, pliable, and strechable.

It has elastic properties - it can be stretched, but will consistently return to it's original shape.

Patient reports removing it manually in the shower without pain.

The patient has a history of pain during vaginal intercourse and during pelvic exams. Regular paps, no history of any STD.

So - what is it? Any ideas?

Sounds like a decidual cast. They are fairly common.

 

[Poety]

Sounds like a decidual cast. They are fairly common.

DING DING DING we have a winner!!!!
http://www2.uchsc.edu/son/camp/edits/time_to_add_decidual_casts_to_th.htm



TIME TO ADD DECIDUAL CASTS TO THE LIST OF RARE DEPO MEDROXYPROGESTERONE ACETATE (DMPA) SIDE EFFECTCTS



CASE REPORTS







Case 1

A sixteen year old female recovering from Anorexia Nervosa presented to clinic for a health maintenance examination. Weight recovery had been noted for six months and she exhibited signs of estrogen stimulation, but was still amenorrheic. For contraception, she had received her first injection of DMPA one month earlier. Although she denied cramping or vaginal bleeding, during her pelvic examination the health care provider removed a large amount of white tissue from her cervical os. Her urine pregnancy test was negative and histology confirmed the diagnosis - decidual cast.





Case 2

A twenty year old female with cerebral palsy and mental ******ation was brought to the clinic by her mother who presented the health care provider with a plastic bag containing a large amount of white tissue which she reported her daughter had passed from her vagina hours earlier. Three weeks earlier, in an effort to minimize hygiene problems related to her erratic pattern of menstrual bleeding - the young woman, who had difficulty swallowing and very sensitive skin, had been given an initial injection of DMPA. Her urine pregnancy test was negative and histology confirmed the diagnosis - decidual cast.





Case 3

An eleven year old Hemophiliac presented to clinic with the complaint of severe menstrual cramps and the sensation of a mass in the vagina. Menarche occurred eight months earlier with an episode of vaginal bleeding that was so heavy that she had to be hospitalized and given a blood transfusion. Since the bleeding was not controlled with oral contraceptives, she was given an injection of DMPA. Her current symptoms resolved after the health care provider removed a large mass of white tissue from her cervical os. Her urine pregnancy test was negative and histology confirmed the diagnosis - decidual cast.





Case 4

An amenorrheic, breastfeeding nineteen year old presented to the clinic 5 months after her third normal, spontaneous vaginal delivery and 2 months after an initial contraceptive injection of DMPA. She complained of vaginal bleeding and abdominal cramping. Speculum examination revealed a large amount of white tissue at the cervical os. When the tissue was removed her symptoms resolved. Her urine pregnancy test was negative and histology confirmed the diagnosis - decidual cast.

 

[baya]

Sounds like a decidual cast. They are fairly common.

Sounds like a match. Thank you!