Stone

Just when I thought I had seen the weirdest that Kenya had to offer....
.....just when I thought my cast list could NOT possibly get more interesting..
...just when I thought I could not get more heartbroken on behalf of a patient......

She came to see me in the office.

The history was very hard to get.  A C section two weeks ago for premature rupture of membranes at 30 weeks.  She waited in a district hospital for two days for a doctor who knew how to do a C section.  Complaints of weeks of pelvic pain and leaking fluid before that. 

I was completely unable to do an exam in the office because she was so uncomfortable.  I suspected she had a vesico-vaginal fistula because of the copious amount of urine that was leaking, so I admitted her to do an exam under anesthesia.

To add to the ambiguity of the situation, I learned that she had presented a few days earlier to the outpatient department when this xray was taken:

After brainstorming with OtherDoc and deciding this might be a bladder stone, I consulted a visiting urologist and asked him to be on stand-by for the exam under anesthesia.

I was putting on my gloves when I heard the surgery resident say, "Dr. Huber, the stone is sitting in the vagina."

Whoa.  Back the truck up.  She has a stone in the vagina?  True, she wouldn't let me touch her in the office yesterday, but...seriously?

I examined her bottom and there it was....a shining white globe the size of my fist.  Dumbfounded - the first thing I thought was - let me go get my forceps and I'll pull it out that way!  On closer examination, the round mass was actually attached by a thin septum to a mass inside the bladder.  A vesiculo-vaginal stone? 

So, I called for one of the long term surgeons and asked the question that everyone dreams of hearing their surgeon say: "Do you think it would be okay if I just pulled this out?"

In the end, I did break the connecting septum and pull out the two pieces of stone.  And this is where it gets strange.

By this time, word had gotten around that something "interesting" was happening in Room 3, so scrub techs, rsidents, visiting staff and the visiting urologist - at least 15 people - had migrated in to see what was going on.  Amidst the crowd, the long term surgeon and I worked to get the large pieces of stone out of the young girl's vagina.  Just as it was twisting to come out, we all saw something....a plastic blue something. 

"There's something in there!"

It was some type of foreign body encrusted inside the stone.  Now, I admit - I was a little freaked out at this point.  And also happy that the patient did not understand english.

After some maneuvering the mass came out in several pieces:

The vaginal "stone"

Vaginal "stone": The whiter area on top (in the middle) is where it was attached
to the bladder stone.

Stone chipped away to reveal the foreign body - bottle cap - within

Baby Bottle Cap: Contraception? Preservation of virginity?  To protect
a pregnancy?  Punishment?

While everyone else marvelled over these events, the urologist and I did another exam.  There were 3 vesico-vaginal fistulas, the most distal one being only 1 cm from the urethral opening.  There was a large fistula opening where the connecting "septum" had been, but overall the tissue looked quite healthy.

A blue baby bottle top....placed in the vagina...that eroded into the anterior vagina, causing mutliple vesico-vaginal fistulas and eventualy was encased into a bladder/vagina stone.

As astounded by the situation as I was, I was more so astounded by the cruelty of these circumstances.  After multiple conversations with the girl and her family, I am no closer to understanding how that bottle top came to be inside her than I was that day in the operating room.  I only know that her life and possibly - her livilihood- are forever altered. It will be weeks before she is able to undergo surgery to repair her fistulas and it will require multiple surgeries.  Money and the overall poor prognosis will be roadblocks to her receiving a "cure".  It is all very crazy and senseless.

And why was it put there?  This was a young, reportedly unmarried girl who had just delivered via C section two weeks prior.  Obviously this foreign body had been there some time - but how long?  And for what reason?  The girl did mention that she was told she was leaking urine and needed a C section - both because of some sort of obstruction.  At least that part of the history makes sense now. 

These are the patients that are my struggle.  Especially at this time of year, when I am torn - already with the melancholoy of missing family and friends.  I miss Thanksgiving, the glitter of Christmas decorations and I even miss Black Friday.  How guilty I feel - to know I am wishing for commericialism when I am caring for a girl who may soon be a social pariah because of her medical condition.  This world - a place of sickness and unexplained cruelty draws me in with the sweet addiction of seeing new things and helping the hopeless...but it also turns me away with the many frustrations of never knowing....why? 

This is a strange story and I'm sorry to end it on a sad note.  But sometimes I am sad and angry and frustrated for my patients.  Behind the sensational stories, I know the people who have lived these tales.  But by sharing their story - and mine-  I hope you will join me in praying for faith and the maintenance of hope.

And a certain woman, which had an issue of blood twelve years, And had suffered many things of many physicians, and had spent all that she had, and was nothing bettered, but rather grew worse.  When she had heard of Jesus, she came in the press behind, and touched his garment. For she said, If I may touch but his clothes, I shall be whole. And straightway the fountain of her blood was dried up; and she felt in her body that she was healed of that plague....... And he said unto her, Daughter, thy faith hath made thee whole; go in peace, and be whole of thy plague.   Mark 5:25-34