Vaginal Stenosis due to Chemical Vaginitis after Using Jamu Sticks: A Case Report

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Abstract

INTRODUCTION

Vaginal stenosis due to chemical vaginitis remains a major public health problem in developing countries where traditional vaginal practices are widely practiced [1]. Although it is rare in most developed countries, problems caused by traditional folk remedies are often reported in countries where alternative medicine is widespread.

Jamu is a traditional folk remedy used in Indonesia and has a variety of applications [2]. In Indonesia, Jamu extracts have been used as a substitute for blood sugar-lowering drugs in type 2 diabetes and as a substitute for antibiotics in infectious diseases. It was also used as a obstetrical folk remedy to induce miscarriage [3], and was also to be used for vaginal cleaning or vaginal tightening.

In fact, in Korea, Jamu stick products and spray products are imported and sold, advertised as vaginal tightening agents or vaginal cleansers. However, indiscriminate use of jamu products can cause allergic reactions, and chemical vaginitis due to chemical reactions. I report a case of a patient successfully treated for vaginal stenosis due to chemical vaginitis caused by Jamu sticks experienced in Soonchunhyang University Bucheon Hospital and advise caution against indiscriminate folk remedies.

CASE REPORT

A 24 -year-old unmarried woman with parity 0-0-0-0 came to emergency center of Soonchunhyang University Bucheon Hospital, presented with a complaint of a foreign body in her vagina. She also complained of severe burning pain in the vulva and vagina along with difficulty in urinating. The patient said she had inserted a piece of Jamu stick, used as a vaginal tightening agent, into her vagina before having sexual intercourse the day before. As the piece did not come out, she was transferred to the university hospital via a local clinic. She said she had frequently used a Jamu stick for vaginal tightening before having intercourse, but it was the first time she had done so with the piece inserted. Her obstetric and gynecological history was unremarkable, and she had been diagnosed with depression 4 years ago and was taking medication.

She had a blood pressure of 112/78 mm Hg, a heart rate of 78 beats/min, a respiratory rate of 18 breaths/min, a temperature of 36.7ºC, and was alert and oriented. Blood tests revealed no abnormalities other than an increase in white blood cells count (WBC count; 15,410/μL) and a mildly elevated C-reactive protein (CRP; 0.77 mg/dL, normal values < 0.5 mg/dL).

The local examination of the genitalia revealed that the area around the vaginal opening and urethra was severely constricted and narrowed. Therefore, insertion of vaginal speculum for vaginal examination and pelvic examination were impossible. It was also assumed that the vulvar skin area suffered a chemical burn due to the Jamu stick component (Fig. 1). After dilation using a uterine sound and a Hegar dilator, the vaginal speculum could be inserted. A moderate amount of foul-smelling fluid was observed inside the vaginal cavity, but no foreign material was observed, so it was assumed to have melted inside the vagina. The vaginal wall had severe ulcers and debris due to chemical burns and showed contact bleeding (Fig. 2).

Fig. 1.

Findings of local examination on the first day of patient visit; the area around the vaginal opening and urethra was severely constricted and narrowed. Written informed consent for the publication of this image was obtained from the patient.

Fig. 2.

Findings of vaginal speculum examination on the first day of patient visit; the vaginal wall had severe ulcers and debris due to chemical burns and showed contact bleeding. Written informed consent for the publication of this image was obtained from the patient.

The patient was diagnosed with vaginal stenosis due to chemical vaginitis caused by a foreign body and was hospitalized. A No. 15 Hegar dilator was placed inside the vagina to prevent further constriction of the narrowed vaginal opening, and a foley catheter inserted in the narrowed urethra to ensure smooth drainage of urine. Intravenous antibiotics (ceftriaxone 2 g/day; Boryung Corp., Seoul, Korea), hemostatic agents, and anti-inflammatory analgesics were administered, and saline irrigation and dressing were performed twice a day in the vulva and vagina, and antibiotic ointment was applied.

On the fourth day of hospitalization, the constricted urethra area improved, therefore the inserted foley catheter was removed and the patient was able to urinate smoothly. On the fifth day of hospitalization, the lesions around the vulva and urethra showed marked improvement, and the contracted vaginal area was also improved (Figs. 3, 4). The urine culture results performed at the first day of hospitalization confirmed Escherichia coli infection, and the urine analysis test and CRP results returned to normal with the antibiotics used during hospitalization. Subsequently, the patient was discharged on the sixth day of hospitalization.

Fig. 3.

Findings of local examination on the fifth day of hospitalization; the lesions around the vulva and urethra showed marked improvement. Written informed consent for the publication of this image was obtained from the patient.

Fig. 4.

Findings of vaginal speculum examination on the fifth day of hospitalization; the contracted vaginal area was also improved. Written informed consent for the publication of this image was obtained from the patient.

She was scheduled to come to the hospital for follow-up outpatient treatment after discharge, but she did not come. However, she had been receiving outpatient treatment in another department of this hospital for more than a year. Therefore, it is presumed that she did not receive follow-up outpatient treatment after discharge because she had no gynecological problems or vaginal restenosis.

DISCUSSION

In developed countries, acquired vaginal stenosis is mostly related to intracavitary radiotherapy for pelvic malignancies or secondary to pelvic surgeries such as colporrhaphy or vaginal hysterectomy [2]. However, in developing countries the situation is completely different, with most cases of vaginal stenosis resulting from chemical vaginitis, birth trauma, or female genital mutilation [4].

Recently, there have been few reports related to vaginal stenosis, and patient cases are rare, so most gynecologists may not be familiar with diagnosing and determining treatment for it [2]. When a patient visits a hospital, the first step is to identify the cause and duration of vaginal stenosis through a medical history, especially an obstetric and gynecological history. Next, the degree of vaginal stenosis should be determined through a local examination of genitalia and a vaginal speculum examination, and, if necessary, imaging tests such as magnetic resonance imaging, and the treatment method should be determined accordingly.

Ugburo et al. [5] designed a severity scale to classify the degree of vaginal stenosis in previous literature. Type 1 is when the vaginal stenosis involving the vulva or introitus only, type 2 is when the vaginal mucosal stenosis, but no complete occlusion, type 3 is when the vaginal stenosis involving the vulva or introitus and vagina with no menstrual disruption, type 4 is when the complete vaginal occlusion or cervical stenosis with hematometra, and type 5 have any of the above deformities with a rectovaginal or vesicovaginal fistula [5].

In patients with the entire length of the vagina is completely obliterated, such as type 4, extensive reconstruction surgery may be required to create a neovagina [5,6]. If the vaginal stenosis is short and there is a sufficient length of normal vagina above and below the stenosis, the stenotic part can be resected and each normal vaginal mucosal end can be reanastomosed [2]. In patients with relatively recently formed and incomplete vaginal stenosis, vaginal dilation can be attempted using a Hegar dilator. In this patient’s case, because the vaginal stenosis was incomplete and very recently formed, vaginal dilation was attempted using a Hegar dilator, which was effective.

Jamu is a traditional Indonesian herbal medicine practice with a long history [2], but not all traditional remedies are safe or effective. Among them, Jamu sticks are used in some Southeast Asian cultures especially Indonesia for vaginal health and tightening. However there is no scientific evidence supporting the safety or effectiveness of Jamu sticks for vaginal tightening or health.

Although Jamu stick is a plant-derived product, it is a foreign substance to the human body and can cause foreign body reactions such as allergic reactions or, in severe cases, anaphylactic shock. Additionally, when used on the vaginal cavity, it can disrupt the vagina’s natural bacterial balance and pH levels, which can lead to irritation or infection, and there is a risk of injury when inserted into the vagina. Chemical reactions caused by these foreign substances can lead chemical vaginitis, increasing the risk of secondary infection through the disrupted vaginal wall [7].

The complications associated with chemical vaginitis can be acute or chronic. Acutely, they cause severe burning, pain, vaginal stricture, or formation of fistula. Chronically, extensive scarring and stenosis of vagina develops, which can further cause amenorrhea, dysmenorrhea, dyspareunia, hematometra and gynatresia [5]. Therefore, it is necessary to determine the presence of complications and take a multidisciplinary treatment approach accordingly.

In cases of simple chemical vaginitis without secondary infection, the lesions may be improved by removing the foreign body and applying a simple dressing. However, if the patient has a fever, shows signs of secondary infection, or has an elevated CRP, antibiotic treatment is absolutely necessary. In this patient, the third-generation cephalosporin was effective in reducing fever, normalizing CRP, and improving the lesion.

In Korea, there are some online markets that sell Jamu sticks over the Internet and introduce them as natural and healthy products. However, caution is required as these lack scientific evidence and can actually result in threatening vaginal health. Products imported from overseas, especially products for human body use, require a thorough inspection of their ingredients and effectiveness. People should also be careful not to misuse or abuse products with unclear ingredients advertised through online markets.

Cases of vaginal stenosis resulting from chemical vaginitis caused by jamu sticks have not been previously reported in the literature. Therefore, this case report is significant in that it is the first and only report of this type of case, which was successfully treated.

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