What treatment is needed for a patient who had a tampon (intrauterine device) left in for 1 week and now has a lingering odor?

Retained Tampon Management

No antibiotic treatment is needed for a retained tampon removed after 1 week in an asymptomatic patient, but clinical evaluation for signs of infection is essential. 1

Immediate Assessment

After tampon removal, evaluate the patient for:

• Fever (temperature >100.4°F/38°C) 1
• Pelvic pain or tenderness 1
• Abnormal vaginal discharge beyond expected odor 1
• Signs of toxic shock syndrome (fever, rash, hypotension, multi-organ involvement) 1

Treatment Algorithm

If Patient is Asymptomatic (No Fever, Pain, or Systemic Symptoms):

• No antibiotics are indicated 1
• The lingering odor is expected from bacterial overgrowth and will resolve spontaneously 1
• Reassurance that odor typically resolves within 2-3 days as normal vaginal flora re-establishes 1

If Patient Has Symptoms (Fever, Pelvic Pain, Foul Discharge):

• Consider bacterial vaginosis as the most common cause of vaginal malodor 1
• Perform vaginal pH testing (pH >4.5 suggests bacterial vaginosis) 1
• Wet mount examination to identify clue cells 1
• If bacterial vaginosis is confirmed: Metronidazole 500 mg orally twice daily for 7 days 1
• If signs of pelvic inflammatory disease: Broader antibiotic coverage is required 1

Managing the Lingering Odor

The odor will resolve spontaneously without intervention in most cases 1. Advise the patient:

• Avoid douching, which disrupts normal vaginal flora and can worsen odor 1
• Normal bathing with mild soap externally only 1
• Expect resolution within 2-5 days as normal lactobacilli re-colonize the vagina 1
• Return if odor persists beyond 1 week or if new symptoms develop 1

Important Caveats

Do not confuse this scenario with retained intrauterine devices (IUDs), which carry different infection risks including Actinomyces when left beyond recommended duration 1. A tampon is not an IUD despite the confusing terminology in the expanded question.

The "whiff test" (fishy odor with KOH) is diagnostic for bacterial vaginosis but is not necessary for management decisions in this clinical scenario 1. The presence of odor alone after foreign body removal does not mandate treatment.

Toxic shock syndrome risk is highest during tampon use, not after removal, but remain vigilant for delayed presentation within 48 hours of removal 1.

Follow-Up Indications

Instruct the patient to return if:

• Fever develops 1
• Pelvic pain worsens or persists 1
• Odor persists beyond 1 week 1
• New vaginal discharge appears (particularly if copious, purulent, or associated with itching) 1