Management of Retained Tampon with Dysuria
Given that the tampon has already been removed and the patient is afebrile without abdominal pain, the primary concern is treating the dysuria, which likely represents a urinary tract infection (UTI) that should be managed with empiric antibiotics while monitoring for signs of toxic shock syndrome or ascending infection.
Immediate Assessment and Monitoring
Evaluate for toxic shock syndrome (TSS): Although the patient is currently afebrile, TSS can present with fever, hypotension, diffuse erythematous rash, and multi-organ involvement. The absence of fever and abdominal pain is reassuring, but close monitoring for 24-48 hours is warranted given the week-long retention. 1
Assess for signs of complicated infection: Check vital signs, examine for suprapubic tenderness, costovertebral angle tenderness, and systemic symptoms. The presence of only dysuria without fever or abdominal pain suggests uncomplicated lower UTI rather than pyelonephritis or systemic infection. 2
Management of Dysuria (Presumed UTI)
Obtain urine culture before starting antibiotics: A clean-catch or catheterized specimen should be collected to identify the causative organism, as E. coli causes approximately 75% of UTIs, with other common pathogens including Enterococcus faecalis, Proteus mirabilis, Klebsiella, and Staphylococcus saprophyticus. 2
Initiate empiric antibiotic therapy immediately: For uncomplicated lower UTI with dysuria alone, start oral antibiotics without waiting for culture results. The most appropriate empiric choices include:
- Nitrofurantoin (if available and no contraindications)
- Trimethoprim-sulfamethoxazole (if local resistance rates <20%)
- Fluoroquinolones (ciprofloxacin or levofloxacin) only if local resistance is <10% and the patient has not used fluoroquinolones in the last 6 months 2
Treatment duration: A standard 3-7 day course is appropriate for uncomplicated lower UTI in women, with 3 days often sufficient for simple cystitis. 1
Evaluation for Vaginal Infection
Assess for bacterial vaginosis or candidiasis: The black, foul-smelling discharge suggests possible bacterial overgrowth or secondary vaginal infection from the retained foreign body. Perform a pelvic examination to evaluate for:
- Vaginal pH (>4.5 suggests bacterial vaginosis)
- Presence of discharge characteristics
- Signs of vulvovaginal inflammation 2
Consider empiric treatment for bacterial vaginosis: Given the prolonged foreign body retention with malodorous discharge, empiric metronidazole 500 mg orally twice daily for 7 days is reasonable even without formal testing, as bacterial vaginosis is common after foreign body retention. 2
Critical Monitoring Parameters
Instruct the patient to return immediately if:
Follow-up within 48-72 hours: Reassess symptoms and review urine culture results to adjust antibiotics if needed. If dysuria persists despite appropriate therapy for a susceptible organism, consider imaging to rule out complicated infection. 1
Common Pitfalls to Avoid
Do not delay antibiotic treatment: Symptomatic UTI requires prompt antimicrobial therapy; waiting for culture results before initiating treatment is inappropriate when symptoms are present. 2, 1
Do not dismiss the risk of ascending infection: While the patient is currently stable, a week-long retained tampon creates significant risk for bacterial colonization that can ascend to cause pyelonephritis or systemic infection if untreated. 2
Do not treat asymptomatic bacteriuria if it develops: If the patient becomes asymptomatic but has positive urine cultures, treatment is not indicated unless she is pregnant or undergoing urologic procedures with anticipated mucosal bleeding. 1
Do not overlook the possibility of concurrent sexually transmitted infections: External dysuria can also be caused by vulvovaginal candidiasis, which may present with vulvar burning and external dysuria. Consider this diagnosis if urinary symptoms persist despite appropriate UTI treatment. 2