What are the treatment and management options for a retained tampon?

Management of Retained Tampon

For patients with a retained tampon, manual extraction should be attempted first as the primary treatment approach, with appropriate imaging only if complications are suspected. 1

Initial Assessment

• Obtain focused history and perform physical examination to determine duration of retention and assess for signs of complications such as fever, unusual discharge, or pelvic pain 1
• Digital vaginal examination should be performed to locate the tampon, but consider obtaining imaging first if there's concern about sharp objects that could cause injury during examination 1
• Laboratory tests are generally not required for uncomplicated retained tampon cases, but should be obtained if signs of infection or toxic shock syndrome are present (fever, rash, hypotension) 1, 2

Imaging Considerations

• Plain X-ray films are typically not necessary for retained vaginal tampons that can be visualized or palpated on examination 1
• If the tampon cannot be located or complications are suspected, consider appropriate imaging:
  • For suspected perforation in hemodynamically stable patients, contrast-enhanced CT scan of the abdomen/pelvis is recommended 1
  • In hemodynamically unstable patients with suspected complications, do not delay treatment for imaging 1

Treatment Algorithm

First-Line Approach

• Manual extraction should be attempted first for accessible retained tampons 1
• Position patient in lithotomy position with adequate lighting 1
• Use a vaginal speculum to visualize the tampon and remove with ring forceps 1
• If the tampon is fragmented or difficult to remove completely, irrigation with sterile saline may help 3

If Initial Extraction Fails

• Consider sedation or anesthesia to improve chances of successful removal:
  • Options include intravenous conscious sedation or regional anesthesia 1
  • This helps relax pelvic floor muscles and reduces patient discomfort 1

Post-Extraction Care

• After removal, perform a thorough examination to ensure complete extraction and assess for mucosal damage 1
• Consider vaginal irrigation with sterile saline to remove any remaining fragments 3

Complications Management

Infection/Toxic Shock Syndrome

• Monitor for signs of toxic shock syndrome (fever, rash, hypotension, multisystem involvement) 2, 4
• If toxic shock syndrome is suspected, initiate:
  • Aggressive fluid resuscitation 2
  • Broad-spectrum antibiotics with coverage for Staphylococcus aureus 1, 2
  • Intensive monitoring and supportive care 5

Fistula Formation

• Rarely, prolonged retention of a tampon can lead to pressure necrosis and fistula formation 3
• If vesicovaginal or rectovaginal fistula is suspected, refer for specialized gynecological evaluation and surgical repair 3

Antibiotic Considerations

• Routine antibiotic prophylaxis is not recommended for uncomplicated retained tampon removal 1
• Reserve antibiotics for cases with:
  • Signs of active infection 1, 2
  • Prolonged retention with significant vaginal discharge or odor 5
  • Mucosal trauma during removal 1

Follow-up Recommendations

• Educate patients about proper tampon use including:
  • Maximum recommended wear time (≤8 hours) 2
  • Using the lowest absorbency needed 4
  • Alternating with pads, especially overnight 2
• Consider follow-up examination if symptoms persist after removal 3

Special Considerations

• For recurrent retained tampons, consider alternative menstrual products 4
• Patients with anatomical variations or previous gynecological surgeries may require specialized approaches 3
• For patients with cognitive impairments, consider caregiver education or alternative menstrual management 1