Should Hysteroscopy Be More Preferably Employed for Treating Vaginal Foreign Bodies in Preadolescent Girls?

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Dehua Wan, Wenting Dong, Liwen Yang, Lijuan Tang, Xiaoqi Jiang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6769599/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Vaginal foreign body (VFB) is an uncommon but clinically important condition in preadolescent gynecology. Timely diagnosis and removal of VFB are essential to prevent complications such as infection, ulceration, and long-term reproductive sequelae. While the use of hysteroscope for vaginoscopy is considered the diagnostic gold standard and enables the surgical removal of the VFB, ultrasound remains more widely used due to its non-invasive nature, low cost and convenience. However, the application of hysteroscopy in the diagnosis and treatment of VFBs in China remains relatively limited due to cultural and socioeconomic factors, as well as anesthesia-related risks. Methods: This retrospective study included 67 pediatric patients with clinically suspected or hysteroscopically confirmed VFBs treated at Chengdu Women’s and Children’s Central Hospital from January 2011 to February 2025. Clinical data were collected, including patient age, symptoms, symptom duration, type of foreign body, pathological findings, hospitalization duration. The diagnostic performance of transabdominal and transperineal ultrasound was compared, using hysteroscopy as the reference gold standard. Results: Among the 67 cases, the most common symptoms were vaginal discharge and bleeding. Textile fibers, hair, and small toys were the most frequently identified VFBs. Transabdominal ultrasound demonstrated a sensitivity, specificity, and accuracy of 58.3%, 41.2%, and 53.8%, respectively. Transperineal ultrasound showed improved sensitivity (75.0%) and accuracy (63.1%) but similarly limited specificity (29.4%). Hysteroscopy facilitates both diagnosis and direct removal of VFBs while avoiding injuring the hymen. Despite its advantages, barriers to hysteroscopy included the need for anesthesia and hospitalization, which may affect parental acceptance. Conclusion: Ultrasound, although commonly used, exhibits poor diagnostic performance in detecting VFB in preadolescent girls. Hysteroscopy, with its superior accuracy and therapeutic capability, should be more preferably considered as diagnostic and treatment modality. vaginal foreign bodies hysteroscopy vaginal endoscopy transabdominal ultrasound transperineal ultrasound preadolescent girls vaginal discharge vaginal bleeding Figures Figure 1 Figure 2 Figure 3 Background Vaginal foreign body (VFB) is a relatively uncommon yet clinically significant concern in preadolescent gynecology. Their clinical presentation varies, with symptoms ranging from asymptomatic cases to persistent vaginal discharge, foul odor, vaginal bleeding, pain, or signs of infection. 1 It has been reported that approximately 4–10% of preadolescent girls presenting with vaginal discharge are found to have an VBF. 1 , 2 The potential risks of VFB in preadolescent girls include vaginal and perineal inflammation, infection, ulceration, and, in severe cases, long-term complications such as vaginal adhesions or scarring, even affecting reproductive health. 3 Timely diagnosis and prompt removal of foreign bodies are crucial for effective management of VFB. Currently, the primary diagnostic modalities include hysteroscopy and ultrasonography, including transperineal and transabdominal ultrasound. The ultrasound examination is most frequently applied when VFB was suspected. However, previous study reported high false negative rates of ultrasound examination on VFB, which indicated that the possibility of a VFB should still be considered in cases of prepubertal vaginal bleeding, vaginal discharge among preadolescent girls, even if sonographic findings appear normal. 4 – 7 Among these, the use of hysteroscope as vaginal endoscopy, is considered the gold standard due to its high diagnostic accuracy and the ability to surgically remove the VFB during the examination. 8 Advances in vaginal endoscopic equipment and techniques in recent years have significantly reduced their invasiveness. 9 – 11 However, due to its potential invasive nature and specific cultural background in China, hysteroscopy for preadolescent girls remains underutilized and is not widely accepted by parents, leading to limited clinical implementation. 12 In contrast, transabdominal and transperineal ultrasound, although non-invasive, carries a risk of misdiagnosis, which may result in delayed treatment in certain cases. 4 – 7 This study analyzed 67 cases of hysteroscopically confirmed or clinically suspected VBF treated at our institution over the past one and half decades. We conducted a comparative evaluation of the diagnostic performance of transabdominal and transperineal ultrasound in detecting vaginal foreign bodies. The primary objective of this study is to assess the diagnostic accuracy of ultrasonography in diagnosing VFB as referencing to hysteroscopy and to evaluate whether the application of hysteroscopy should be expanded as a better diagnostic tool for preadolescent patients as compared with ultrasonography. Method Study design This retrospective study included all 67 cases of clinically suspected or hysteroscopically confirmed VFBs managed at Chengdu Women’s and Children’s Central Hospital between January 2011 and February 2025. Data collected included patient age, main clinical manifestations, duration of symptoms, pathological findings, type of VFBs, duration of hospital stay, and total medical expenses. Additionally, we also compared the diagnostic performance of transabdominal and transperineal ultrasound in detecting VFBs by evaluating their sensitivity, specificity, and overall accuracy. Diagnosis of VFB The diagnosis of VFB in young girls is based on a combination of clinical history, physical examination, imaging, and hysteroscopic evaluation: Medical history: A detailed history was obtained from the child or caregiver, including any report of suspected foreign body insertion, as well as the presence of symptoms such as abnormal vaginal discharge, foul odor, bleeding, vulvar irritation, or itching. Physical examination: Inspection of the vulva revealed hyperemia and congestion, along with bloody, purulent, or foul-smelling discharge. Digital rectal examination detected a palpable foreign body. Ultrasonography: the detection of echogenic foreign materials within the vaginal canal under transabdominal or transperineal ultrasound. Hysteroscopic examination (diagnostic gold standard): VFB identified under hysteroscopic visualization. Transabdominal and Transperineal Ultrasound Examinations Ultrasound examinations were conducted in a similar manner as the protocols described in previous literature. 6 , 13 , 14 All scans were performed using the Phillip CX50 (Koninklijke Philips N.V., Amsterdam, the Netherlands) and Samsung WS80A (Samsung Medison Co., Ltd., Seoul, South Korea). 14 , 15 The curved array probes at a frequency range of 1–5 MHz and linear array probes at 3–12 MHz were applied in our study. Medical ultrasonic couplants (Cores, Shanghai, China) was applied to ensure optimal acoustic contact between the probe and the patient’s skin. Transperineal sonography was performed using both curved array and linear array probes. In some cases, the curved array probe was initially employed to provide an overall view and to identify the general characteristics of the VFB. Subsequently, a linear array probe, with higher resolution, was used for more detailed examination of the area where the VFB was present. Scans were acquired with the patient in the supine position, while older children were placed in a modified lithotomy position as needed. The probe was positioned externally over the vaginal introitus. Sagittal perineal images were obtained and archived. Transabdominal sonography was conducted with the patient’s bladder adequately distended. Curved array probe was employed to acquire sagittal perineal images of the upper vaginal canal, which were then stored for analysis. In cases involving uncooperative children, sonographers would calm the child and waited for the child’s voluntary cooperation; no sedation or anesthesia was administered to facilitate cooperation. All ultrasound assessments were performed by experienced pediatric and gynecologic sonologists. The ultrasound characteristics of the VFBs, and their size, and distance from the vaginal introitus, were all documented in the report. Hysteroscopic examination and surgical removal of VFBs The hysteroscopic examination and surgical removal of VFBs were performed according to the indications and procedures outlined in previously published practice guidelines. 9 , 16 , 17 In the present study, we utilized the IMAGE1 S H3-LINK hysteroscopy system and the CAMPO TROPHYscope hysteroscope (KARL STORZ SE & Co. KG, Tuttlingen, Germany) with a outer diameter of 10mm (Fig. 1 ) for both diagnostic and operative hysteroscopy. The procedure did not involve entry into the uterine cavity, and meticulous care was taken to avoid compromising the patient's hymen and vaginal mucosa. 11 The indications and procedural steps are detailed as follows. 1.Indications The removal of VFB is one of the primary indications for hysteroscopy. In this study, we specified the indications and contraindications for hysteroscopic examination and the surgical removal of VFBs as follows. 1) Indications: (1) a history of suspected VFB reported by the patient or caregivers; (2) clinical manifestations and physical examination findings suggest VFB, such as abnormal vaginal discharge, foul odor, vulvar pruritus, or pain; (3) imaging evidence of VFB identified by transabdominal or transperineal ultrasound. 2) Contraindications: (1) spontaneous expulsion of the VFB with complete resolution of clinical symptoms; (2) presence of acute genital tract infection; (3) poor cardiopulmonary or general medical condition that precludes safe anesthesia or surgery; In cases where spontaneous expulsion of a VFB is suspected but symptoms persist, hysteroscopy was still performed to assess any residual fragments or additional VBFs. 2. Procedures Throughout the entire procedure, the hysteroscope was inserted only into the vaginal canal without entering the uterine cavity. Special attention was paid to protecting the vaginal mucosa and avoiding additional trauma. Images illustrating the key procedures of hysteroscopy in this study are presented in Fig. 2 . The detailed steps of the procedure are as follows: Anesthesia: All procedures were performed under general anesthesia to ensure safety and minimize discomfort. Aseptic preparation: Routine perineal disinfection and sterile draping were performed. Insertion of the hysteroscope: The hysteroscope was gently inserted through the vaginal introitus under direct vision. Irrigation: Sterile saline was used as the distension medium. It was introduced through the inflow channel of the hysteroscope and drained through the outflow channel, allowing for clear visualization of the vaginal walls and fornices. Detection and removal of foreign body: Once a foreign body was identified under hysteroscopic visualization (Fig. 2 A), it was carefully extracted using hysteroscopic grasping forceps or biopsy forceps introduced through the working channel (Fig. 2 B). In cases where the foreign body was large or fragmented, it was gently segmented and removed piece by piece to avoid trauma to the vaginal mucosa. Examination of the cervix and vaginal mucosa: After the removal of the foreign body, inspect the local vaginal mucosa at the site of the removed VFB (Fig. 2 C), examine the cervix (Fig. 2 D), and subsequently check other areas of the vaginal mucosa for any residual foreign bodies or remnants (Fig. 2 E). Upon completion of the procedure, the patient was monitored until full recovery from anesthesia. The removed tissue was presented to the patient's guardian for confirmation. Statistical analysis Data was processed using SPSS version 27.0 (IBM Corp., Armonk, NY, USA) and Microsoft Excel (Microsoft Corp., Redmond, WA, USA). Categorical variables are presented as counts and percentages. The analysis of the comparative diagnostic performance of transabdominal and transperineal ultrasound was conducted with reference to the methodologies described in previous studies. 6 , 18 Results Sociodemographic and Clinical Features of 67 Chinese Preadolescent Girls with VFB Table 1 listed the sociodemographic characteristics and clinical features of 67 pediatric patients diagnosed with vaginal foreign bodies (VFB). The patients’ ages ranged from 2 to 11 years, with the most common age being 6 years (23.88%), followed by ages 4 and 5 (each 13.43%). The predominant clinical manifestation was purulent vaginal discharge, observed in 50.75% of cases, followed by vaginal bleeding or blood-stained discharge (40.30%). Less common symptoms included foul-smelling discharge (10.45%), perineal redness and swelling (4.48%), genital itching (4.48%), perineal pain (1.49%), and right lower abdominal pain (1.49%). Regarding symptom duration, 38.81% of patients had symptoms lasting from one month to one year. Durations of 1 week to ≤ 1 month and more than one year were reported in 20.90% and 11.94% of cases, respectively. Types of VFB identified included textile materials (25.37%), unknown objects (8.96%), plastic fragments (5.97%), marbles (4.48%), nails (2.99%), stationery items such as pen caps, erasers, and pencils (2.99%), coins (2.99%), hair (2.99%), building blocks (2.99%), buttons (2.99%), paper (2.99%), and springs (1.49%). In 25.37% of cases, no foreign body was detected during hysteroscopic evaluation. Two cases involved spontaneous expulsion of the foreign body and recovery of clinical sympto prior to hysteroscopy and one patient had both hair and textile fibers identified during hysteroscopy. Pathological examination was not performed in the majority of cases (83.59%). Among the 13 cases underwent pathologic examination, findings included acute vulvitis (10.45%), chronic vulvitis (1.49%), cervical Nabothian cyst (1.49%), precocious puberty (2.99%), urethral polyp (1.49%), and vaginal polyp (1.49%). Hospitalization duration was predominantly short, with 50.75% of patients hospitalized for 2 days, and 38.81% for 1 day. Only a small proportion stayed for more than 3 days(about 10%). Table 1 Sociodemographic and Clinical Features of Girls with suspected VFB Number of cases(N = 67) Percentage(%) Age(years) 2 4 5.97 3 7 10.45 4 9 13.43 5 9 13.43 6 16 23.88 7 6 8.96 8 8 11.94 9 2 2.99 10 4 5.97 11 2 2.99 Main clinical manifestations Purulent vaginal discharge 34 50.75 Vaginal bleeding or blood-stained vaginal discharge 27 40.30 Foul-smelling vaginal discharge 7 10.45 Perineal redness and swelling 3 4.48 Genital itching 3 4.48 Perineal pain 1 1.49 Right lower abdominal pain 1 1.49 Duration of symptoms ≤ 1 day 10 14.93 1 day to ≤ 1 week 9 13.43 1 week to ≤ 1 month 14 20.90 1 month to ≤ 1 year 26 38.81 Longer than 1 year 8 11.94 Types of VFB* No foreign body was found under hysteroscopy 17 25.37 Textile materials 17** 25.37 Unknown subjects 6 8.96 Plastic tubes or fragments 4 5.97 Marbles 3 4.48 Nails 2 2.99 Stationery items (pen caps, erasers, pencils) 2 2.99 Coin 2 2.99 Hair 2** 2.99 Building block 2 2.99 Buttons 2 2.99 paper 2 2.99 Springs 1 1.49 Findings of pathological examinations Did not undergo pathological examinations 56 83.59 Acute vulvitis 7 10.45 Chronic vulvitis 1 1.49 Cervical Nabothian cyst 1 1.49 Urethral polyp 1 1.49 Vaginal polyp 1 1.49 Duration of hospitalization(days) 1 26 38.81 2 34 50.75 3 3 4.48 4 3 4.48 5 1 1.49 Note: * There were two cases of spontaneous expulsion of the VFb **Hysteroscopic examination revealed the simultaneous presence of hair and Textile materials in one case. ***Higher medical cost due to the surgical removal of urethral polyps Abbreviation: VFB, vaginal foreign body Diagnostic performance of transabdominal ultrasound and transperineal ultrasound in the evaluation of VFB among Tables 2 , 3 and 4 summarized the diagnostic performance of transabdominal ultrasound and transperineal ultrasound in the evaluation of VFBs, using hysteroscopy as the reference standard. Representative transabdominal ultrasound photos of the VFBs were shown in Fig. 3 A &B . Due to spontaneous expulsion of VFBs in two girls, the diagnostic performance analysis included only the remaining 65 patients who underwent both hysteroscopy and ultrasonography. For transabdominal ultrasound, the sensitivity, specificity, and accuracy were 58.3%, 41.2%, and 53.8%, respectively, based on 28 true positives, 10 false positives, 20 false negatives, and 7 true negatives. In contrast, transperineal ultrasound demonstrated improved sensitivity and overall diagnostic accuracy, with a sensitivity of 75.0%, specificity of 29.4%, and accuracy of 63.1%, derived from 36 true positives, 12 false positives, 12 false negatives, and 5 true negatives. These findings suggest that transperineal ultrasound may be more sensitive and slightly more accurate than transabdominal ultrasound in detecting VFB, albeit both modalities exhibit limited specificity. Table 2 Two-per-two table on the performance of transabdominal ultrasound for the evaluation of VFB Hysteroscopy Total Confirmed VFB VFB not detect4ed Transabdominal Ultrasound Positive 28 10 38 Negative 20 7 27 Total 48 17 65 Abbreviation: VFB, vaginal foreign body Table 3 Two-per-two table on the performance of transperineal ultrasound for the evaluation of VFB Hysteroscopy Total Confirmed VFB VFB not detect4ed Transperineal Ultrasound Positive 36 12 48 Negative 12 5 17 Total 48 17 65 Abbreviation: VFB, vaginal foreign body Table 4 Summarized result of the diagnostic performance of transabdominal ultrasound and transperineal ultrasound in diagnosing VFB Sensitivity Specificity Accuracy Transabdominal Ultrasound 0.583 0.412 0.538 Transperineal Ultrasound 0.750 0.294 0.631 Abbreviation: VFB, vaginal foreign body Discussion VFBs in young girls are relatively uncommon in clinical practice. Due to the absence of large-scale cohort studies, accurate data on the incidence and prevalence of VFBs in the pediatric and adolescent populations remain scarce. A commonly referenced study reported a prevalence of approximately 4% among girls under the age of 13 in the United States. 19 VFB are of diverse categories and often challenging to identify, particularly in pediatric patients who are unable to accurately describe or report their medical history. The limited resolution of ultrasound in distinguishing VFB frequently contributes to missed diagnosis and delayed treatment. 4 Most existing literature has focused on individual case reports or retrospective analyses of the clinical presentations and ultrasonographic features of VFBs. 6 However, few studies have systematically compared the diagnostic performance of transabdominal ultrasound, transperineal ultrasound, and hysteroscopy. 5 , 6 , 20 In current clinical practice for the diagnosis and management of VFBs, hysteroscopy has demonstrated reliable diagnostic efficacy. Previously published articles have shown a certain degree of inconsistency in the use of terms such as hysteroscopy, vaginoscopy, and vaginal endoscopy for describing similar diagnostic and endoscopic modality. 7 , 8 , 10 , 11 , 21 , 22 Our study involved the use of hysteroscope for vaginoscopy, also referred as vaginal endoscopy, which avoids the use of a vaginal speculum thus more suitable for treating preadolescent girls. 9 Under hysteroscopy, when a foreign body is identified, it can be removed during the examination. A systematic review including six randomized controlled trials(RCT) found no significant difference in diagnostic accuracy between vaginal endoscopy and conventional hysteroscopy; however, vaginal endoscopy was associated with significantly shorter procedure times and reduced patient pain. 17 Another systematic review and meta-analysis found that, compared to traditional hysteroscopy, vaginal endoscopy significantly reduced both examination duration and patient discomfort. Moreover, the incidence of postoperative complications was also markedly lower in the vaginal endoscopy group. 23 A rigid hysteroscopy setting can be applied as the diagnostic and operative vaginal endoscopy for treating VFB, and its feasibility was demonstrated as early as 1995, when a Taiwanese team reported the hysteroscopic extraction of a VFB in a 3.5 year old girl. 10 In a 2007 retrospective study from Turkey, 26 women aged 17 to 54 who had preserved their virginity for religious or personal reasons were evaluated using a rigid hysteroscope. The clinicians successfully diagnosed and removed VFBs, cervical polyps, and a subserous myoma without damaging the hymen. 24 Recently, a case of successful vaginal endoscopic excision of the vaginal septum in a virgin girl with obstructed hemivagina and ipsilateral renal anomaly has also been reported. 25 These findings collectively suggest that hysteroscopy or vaginal endoscopy can enable accurate diagnosis and effective removal of tumors or foreign bodies without compromising the integrity of the hymen. The utilization of hysteroscopy for treating VFB among young girls in China remains limited probably due to the cultural background and the conservative perception toward such invasive examinations method among Chinese guardians of the pediatric patients, which may lead to treatment delays. 12 Although it was suggested that the use of smaller endoscopes could reduce invasiveness, our findings demonstrate that even with the routinely used endoscopic system in our institution, featuring an outer diameter of 10 mm, no perioperative complications were observed. Under general anesthesia, the resulting muscle relaxation allows for greater distensibility, enabling the insertion of the endoscope without damaging the hymen, including younger girls whose hymenal development is typically incomplete. Moreover, the 10 mm diameter hysteroscope offers a more spacious operative field, allowing the use of clamps for the removal of larger foreign bodies. The requirement for anesthesia and hospitalization, typically lasting one to two days, for hysteroscopic examination may further reduce parents’ willingness to choose hysteroscopy as a diagnostic modality for VFB. The hysteroscopy was carefully performed without interfering the hymen. Moreover, with recent advancements in equipment and instrumentation, its invasiveness has been significantly reduced. Our evidence indicates that the diagnostic criteria for employing hysteroscopy in cases of VFBs can be appropriately broadened. Additionally, it is essential to address and modify parents’ preexisting perceptions by clearly outlining the advantages, disadvantages, indications, and safety profiles of the two examination methods. In our cohort, the majority of VFBs were composed of textile fibers, hair, stationery items, and small toys. It is worth noting that textile materials and similar substances are inherently difficult to visualize on ultrasound, which we speculate may contribute to the lower sensitivity of both transabdominal and transperineal ultrasound in our study compared to findings reported in another domestic study on this issue. 6 This may also contribute to delayed diagnosis and treatment in some patients. 4 In our cohort, some children experienced symptoms lasting more than one year, with one case persisting for over two years. Notably, although the overall age distribution was skewed toward younger children, those aged over 8 years still accounted for nearly one-eighth of the cohort, but obtaining accurate clinical histories from such a pediatric population was still particularly challenging. Despite the use of hysteroscopy as the diagnostic gold standard, 17 children in our cohort showed no evidence of VFB upon hysteroscopic examination. However, these patients presented with clinical complaints and histories highly suggestive of VFB, and many had a prolonged symptom duration. We suspect that spontaneous expulsion of the foreign bodies may have occurred prior to the examination. Similarly, a comparable study investigating the diagnostic performance of transabdominal and transperineal ultrasound for detecting VFBs in young girls reported that approximately 40% of cases had VFB-like symptoms or a history of inserting objects into the vagina, yet no foreign body was detected upon examination. 6 A recent study from Australia also reported that only 43.3% vaginoscopies yielded a positive diagnosis among prepubertal girls with vaginal discharge or bleeding. 7 Sexual abuse is one of the causes of VFBs. However, the incidence of VFBs associated with child sexual abuse remains poorly documented. A previous literature published two decades ago reported that, in the United States, it is estimated that approximately 1% of girls are subjected to sexual violence, while around one quarter having encountered some form of inappropriate sexual behavior. 26 An early retrospective case review by Herman-Giddens reported that 11 out of 12 prepubertal girls evaluated for VFBs were either suspected or confirmed victims of sexual abuse, however, none of the 67 pediatric cases included in our study were attributed to such factors. 27 In general, VFBs in preadolescent girls need to be differentiated from vulvovaginitis. 28 In this study, 9 cases, accounting for nearly 12% of the cohort, were involved with vulvovaginitis. Common symptoms of pediatric vulvovaginitis include vulvar erythema, pruritus, abnormal vaginal discharge, and dysuria. On the other hand, the prolonged presence of a vaginal foreign body may also lead to recurrent episodes of vulvovaginitis, particularly persistent or treatment-resistant cases in young girls. In clinical practice, diagnosis is typically established through a combination of transabdominal or transperineal ultrasonography and hysteroscopy. 28 The most effective approach to preventing VFB of preadolescent girls is undoubtedly to enhance supervision and cares. To reduce the risk of VFB in preadolescent girls, we propose the following measures:1) Avoid the use of open-crotch pants: In China, there has traditionally been a practice of dressing toddlers in open-crotch pants to facilitate toilet training, which has been declined significantly recently due to the widespread adoption of disposable diaper. 29 Open-crotch pants expose the external genitalia, increasing the risk of perineal trauma and genital infections. Additionally, they may hinder the development of children’s awareness of bodily privacy and heighten curiosity toward their genital areas, thereby increasing the risk of VFB; 20 2) Pay attention to children’s physical and emotional well-being and promote hygiene education. Young children are curious and tend to explore their surroundings as well as their own bodies. Early education can help children understand changes in their bodies, particularly those associated with puberty, in a constructive and informed way; 4) Provide timely and appropriate sex education. Parents should help children recognize their genital organs and understand the importance of protecting their private areas. Children should be taught to refuse inappropriate physical contact, especially involving private parts, and to report any uncomfortable or suspicious interactions to trusted adults; 26 5) Avoid behavioral imitation. For example, mothers who are administering vaginal medication should ensure that young girls are not present during the process, as such exposure may lead to behavioral imitation. This pilot study has several limitations, including a small sample size, a retrospective design, and a single-center setting, which may restrict the generalizability of our findings. However, the strengths lie in the comprehensive evaluation of the prognosis for pediatric patients with VFB that were initially missed by ultrasound, as well as the detailed assessment of clinical manifestations and their total medical cost in preadolescent patients with suspected VFB. A prospective study with a larger cohort would provide more robust evidence to guide pediatric gynecologists in selecting the most appropriate diagnostic strategies for VFB. Conclusion Ultrasound examination, including both transabdominal and transperineal approaches, demonstrates unsatisfactory diagnostic performance in diagnosing VFB. Hysteroscopy is not only the gold standard for the diagnosis of VFB but also enables the surgical removal of VFBs. Hysteroscopy should be considered the preferred modality for VFB management, but its requirement for anesthesia, hospitalization, and relatively higher medical costs may limit its acceptability among families of preadolescent patients of VFB in China. Declarations Ethical statement This study was conducted in accordance with the ethical approval of the institutional review committee of Chengdu Women’s and Children’s Central Hospital (202566) and the 1964 Helsinki Declaration. Written informed consent for participation and publication of anonymized data was obtained from the patients' parents or legal guardians prior to the initiation of the study. Availability of data and materials Data is provided within the manuscript or supplementary information files. Competing interests The authors declared no competing interests. Funding This study was financially funded by the Japan-China Sasakawa Fellowship Program (No.4408) and the Yingcai Scheme of Chengdu Women’s and Children’s Central Hospital (No.YC2023004). Author contribution The study was conceptualized by Dehua Wan and Tianjiao Liu. Data collection was conducted by Dehua Wan, Xiaoqi Jiang, Wenting Dong, and Lijuan Tang. The ultrasound examinations and diagnoses were performed by Liwen Yang and Sheng Yang. Data analyses were performed by Tianjiao Liuand Dehua Wan. The manuscript was drafted by Tianjiao Liu and Dehua Wan. Project supervision was jointly undertaken by Dehua Wan, Tianjiao Liu, Zhi Chen, and Sheng Yang. All authors contributed to the revision of the manuscript and provided final approval for its publication. Acknowledgements None References Umans E, Boogaerts M, Vergauwe B, Verest A, Van Calenbergh S. Vaginal foreign body in the pediatric patient: A systematic review. Eur J Obstet Gynecol Reprod Biol. 2024;297:153–8. 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Clinical presentation, diagnosis and treatment of vulvovaginitis in girls: a current approach and review of the literature. World J pediatrics: WJP. 2017;13(2):101–5. Lukowski AF, Liu X, Peirano P, Odio M, Bauer PJ. Disposable diaper use promotes consolidated nighttime sleep and positive mother-infant interactions in Chinese 6-month-olds. J family psychology: JFP : J Div Family Psychol Am Psychol Association (Division 43). 2015;29(3):371–81. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6769599","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475683419,"identity":"e76e7e97-f175-4627-b5b8-6f159edd3019","order_by":0,"name":"Dehua Wan","email":"","orcid":"","institution":"Chengdu Women’s and Children’s Central Hospital, University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Dehua","middleName":"","lastName":"Wan","suffix":""},{"id":475683420,"identity":"9b655391-603f-4879-a06c-f213d2b04199","order_by":1,"name":"Wenting Dong","email":"","orcid":"","institution":"Sichuan Jinxin Xinan Women and Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wenting","middleName":"","lastName":"Dong","suffix":""},{"id":475683421,"identity":"4cfbbd2a-2373-4cb3-ac53-551902422623","order_by":2,"name":"Liwen Yang","email":"","orcid":"","institution":"Chengdu Women’s and Children’s Central Hospital, University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Liwen","middleName":"","lastName":"Yang","suffix":""},{"id":475683422,"identity":"bcc18677-ece0-4b59-a0ec-6d5694faa27e","order_by":3,"name":"Lijuan Tang","email":"","orcid":"","institution":"Chengdu Women’s and Children’s Central Hospital, University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Lijuan","middleName":"","lastName":"Tang","suffix":""},{"id":475683423,"identity":"18a908f5-dd6d-4145-b477-76259e28df5f","order_by":4,"name":"Xiaoqi Jiang","email":"","orcid":"","institution":"Statistical Room of Medical Record, Chengdu Women’s and Children’s Central Hospital, University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Xiaoqi","middleName":"","lastName":"Jiang","suffix":""},{"id":475683424,"identity":"126b6626-59ff-45df-a8f3-0cbc18cf9d71","order_by":5,"name":"Sheng Yang","email":"","orcid":"","institution":"Chengdu Women’s and Children’s Central Hospital, University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Sheng","middleName":"","lastName":"Yang","suffix":""},{"id":475683425,"identity":"aa480ddf-225a-4655-8b76-a624b6604d61","order_by":6,"name":"Zhi Chen","email":"","orcid":"","institution":"Chongqing Tradition Chinese Medicine Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhi","middleName":"","lastName":"Chen","suffix":""},{"id":475683426,"identity":"3be34567-dd8b-4eac-9061-5c93f8041545","order_by":7,"name":"Tianjiao Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBACPmYgkcDAwMwG4klU2MixsTcfwKuFjZmBsQGqhbFB4kyaMR/PsQT8WkAqoWzGBsaWQ4nzJHIU8Gth5zF/8KDmDjsf++HjDywbDqS3MeQwMPyo2IbHYTyGDQnHnjGz8aQlNkjuuJPbxnD2AGPPmdsEtLAdBvolx7BB8syz3DbGvgRmxjZCWv4BtfC/AWppO5wOFDEgrCWxDahFIgesJYGNjaAWtsIZiX0gLc8SZwAD2bCNhy3hID6/8PMf3vDxx7fDyfL9yQc+A6NSXn7+44MPflTg1gIDySCCWQLKO0BQPRDYgQjGD8QoHQWjYBSMghEHAEqnUxAYtBlFAAAAAElFTkSuQmCC","orcid":"","institution":"Chengdu Women’s and Children’s Central Hospital, University of Electronic Science and Technology of China","correspondingAuthor":true,"prefix":"","firstName":"Tianjiao","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-05-28 15:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6769599/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6769599/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85649347,"identity":"4059d2d9-3fbb-44f3-ba58-b55dcbe7bc95","added_by":"auto","created_at":"2025-06-30 08:55:59","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2127369,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePhotos of the hysteroscope used in present study.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Grasping forceps of the CAMPO TROPHYscope\u003c/p\u003e\n\u003cp\u003eB. Unassembled continuous-flow operating sheath\u003c/p\u003e\n\u003cp\u003eC. Assembled continuous-flow operating sheath\u003c/p\u003e\n\u003cp\u003eD. Assembled CAMPO TROPHYscope with continuous-flow operative sheath and grasping forceps\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6769599/v1/145ce086097a46252b43f772.jpg"},{"id":85649348,"identity":"ab3aeec8-f329-4815-8356-42805a41e1a5","added_by":"auto","created_at":"2025-06-30 08:55:59","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2247048,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKey procedures of hysteroscopic examination and surgical removal of VFB\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA.\u003c/strong\u003e Identification of the VFB (textile fibers) under hysteroscopy\u003c/p\u003e\n\u003cp\u003eB. Removal of the VFB\u003c/p\u003e\n\u003cp\u003eC. Inspection of the local vaginal mucosa at the site of the removed VFB\u003c/p\u003e\n\u003cp\u003eD. Examination of the cervical os after removal\u003c/p\u003e\n\u003cp\u003eE. Evaluation of other areas of the vaginal mucosa for residual foreign bodies or remnants\u003c/p\u003e\n\u003cp\u003eAbbreviation: VFB, vaginal foreign body\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6769599/v1/9a5d068c1efa24bb4912880d.jpg"},{"id":85649350,"identity":"2a93c34f-e687-4836-9cef-307ad2d68559","added_by":"auto","created_at":"2025-06-30 08:55:59","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1450308,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRepresentative transabdominal ultrasound photos of VFBs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. An arc-shaped hyperechoic structure measuring approximately 1.0 cm in length observed in the upper vaginal segment near the internal cervical os. The structure appeared relatively fixed in shape and position, with posterior acoustic shadowing. Transperineal ultrasound revealed that the hyperechoic structure was located approximately 4.8 cm from the vaginal introitus.\u003c/p\u003e\n\u003cp\u003eB. A mildly hyperechoic structure measuring approximately 1.3 × 0.7 × 0.4 cm detected in the upper vaginal segment beneath the cervix. The structure had well-defined margins and a regular shape, with no evident internal blood flow on Doppler imaging.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6769599/v1/181d9729d5cde7a9ba516888.jpg"},{"id":101397910,"identity":"71accd69-a1f1-4a7a-9222-039ca032b310","added_by":"auto","created_at":"2026-01-29 09:38:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6754557,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6769599/v1/facdf52f-b8da-4bb5-b1a2-ecb827d7e592.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Should Hysteroscopy Be More Preferably Employed for Treating Vaginal Foreign Bodies in Preadolescent Girls?","fulltext":[{"header":"Background","content":"\u003cp\u003eVaginal foreign body (VFB) is a relatively uncommon yet clinically significant concern in preadolescent gynecology. Their clinical presentation varies, with symptoms ranging from asymptomatic cases to persistent vaginal discharge, foul odor, vaginal bleeding, pain, or signs of infection.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e It has been reported that approximately 4\u0026ndash;10% of preadolescent girls presenting with vaginal discharge are found to have an VBF.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The potential risks of VFB in preadolescent girls include vaginal and perineal inflammation, infection, ulceration, and, in severe cases, long-term complications such as vaginal adhesions or scarring, even affecting reproductive health.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTimely diagnosis and prompt removal of foreign bodies are crucial for effective management of VFB. Currently, the primary diagnostic modalities include hysteroscopy and ultrasonography, including transperineal and transabdominal ultrasound. The ultrasound examination is most frequently applied when VFB was suspected. However, previous study reported high false negative rates of ultrasound examination on VFB, which indicated that the possibility of a VFB should still be considered in cases of prepubertal vaginal bleeding, vaginal discharge among preadolescent girls, even if sonographic findings appear normal.\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Among these, the use of hysteroscope as vaginal endoscopy, is considered the gold standard due to its high diagnostic accuracy and the ability to surgically remove the VFB during the examination.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Advances in vaginal endoscopic equipment and techniques in recent years have significantly reduced their invasiveness.\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e However, due to its potential invasive nature and specific cultural background in China, hysteroscopy for preadolescent girls remains underutilized and is not widely accepted by parents, leading to limited clinical implementation.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e In contrast, transabdominal and transperineal ultrasound, although non-invasive, carries a risk of misdiagnosis, which may result in delayed treatment in certain cases. \u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study analyzed 67 cases of hysteroscopically confirmed or clinically suspected VBF treated at our institution over the past one and half decades. We conducted a comparative evaluation of the diagnostic performance of transabdominal and transperineal ultrasound in detecting vaginal foreign bodies. The primary objective of this study is to assess the diagnostic accuracy of ultrasonography in diagnosing VFB as referencing to hysteroscopy and to evaluate whether the application of hysteroscopy should be expanded as a better diagnostic tool for preadolescent patients as compared with ultrasonography.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis retrospective study included all 67 cases of clinically suspected or hysteroscopically confirmed VFBs managed at Chengdu Women\u0026rsquo;s and Children\u0026rsquo;s Central Hospital between January 2011 and February 2025. Data collected included patient age, main clinical manifestations, duration of symptoms, pathological findings, type of VFBs, duration of hospital stay, and total medical expenses. Additionally, we also compared the diagnostic performance of transabdominal and transperineal ultrasound in detecting VFBs by evaluating their sensitivity, specificity, and overall accuracy.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDiagnosis of VFB\u003c/h3\u003e\n\u003cp\u003eThe diagnosis of VFB in young girls is based on a combination of clinical history, physical examination, imaging, and hysteroscopic evaluation:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMedical history: A detailed history was obtained from the child or caregiver, including any report of suspected foreign body insertion, as well as the presence of symptoms such as abnormal vaginal discharge, foul odor, bleeding, vulvar irritation, or itching.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePhysical examination: Inspection of the vulva revealed hyperemia and congestion, along with bloody, purulent, or foul-smelling discharge. Digital rectal examination detected a palpable foreign body.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUltrasonography: the detection of echogenic foreign materials within the vaginal canal under transabdominal or transperineal ultrasound.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHysteroscopic examination (diagnostic gold standard): VFB identified under hysteroscopic visualization.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eTransabdominal and Transperineal Ultrasound Examinations\u003c/h3\u003e\n\u003cp\u003eUltrasound examinations were conducted in a similar manner as the protocols described in previous literature.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e All scans were performed using the Phillip CX50 (Koninklijke Philips N.V., Amsterdam, the Netherlands) and Samsung WS80A (Samsung Medison Co., Ltd., Seoul, South Korea).\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e The curved array probes at a frequency range of 1\u0026ndash;5 MHz and linear array probes at 3\u0026ndash;12 MHz were applied in our study. Medical ultrasonic couplants (Cores, Shanghai, China) was applied to ensure optimal acoustic contact between the probe and the patient\u0026rsquo;s skin. Transperineal sonography was performed using both curved array and linear array probes. In some cases, the curved array probe was initially employed to provide an overall view and to identify the general characteristics of the VFB. Subsequently, a linear array probe, with higher resolution, was used for more detailed examination of the area where the VFB was present. Scans were acquired with the patient in the supine position, while older children were placed in a modified lithotomy position as needed. The probe was positioned externally over the vaginal introitus. Sagittal perineal images were obtained and archived. Transabdominal sonography was conducted with the patient\u0026rsquo;s bladder adequately distended. Curved array probe was employed to acquire sagittal perineal images of the upper vaginal canal, which were then stored for analysis. In cases involving uncooperative children, sonographers would calm the child and waited for the child\u0026rsquo;s voluntary cooperation; no sedation or anesthesia was administered to facilitate cooperation. All ultrasound assessments were performed by experienced pediatric and gynecologic sonologists. The ultrasound characteristics of the VFBs, and their size, and distance from the vaginal introitus, were all documented in the report.\u003c/p\u003e\n\u003ch3\u003eHysteroscopic examination and surgical removal of VFBs\u003c/h3\u003e\n\u003cp\u003eThe hysteroscopic examination and surgical removal of VFBs were performed according to the indications and procedures outlined in previously published practice guidelines. \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e In the present study, we utilized the IMAGE1 S H3-LINK hysteroscopy system and the CAMPO TROPHYscope hysteroscope (KARL STORZ SE \u0026amp; Co. KG, Tuttlingen, Germany) with a outer diameter of 10mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) for both diagnostic and operative hysteroscopy. The procedure did not involve entry into the uterine cavity, and meticulous care was taken to avoid compromising the patient's hymen and vaginal mucosa.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e The indications and procedural steps are detailed as follows.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e1.Indications\u003c/p\u003e \u003cp\u003eThe removal of VFB is one of the primary indications for hysteroscopy. In this study, we specified the indications and contraindications for hysteroscopic examination and the surgical removal of VFBs as follows.\u003c/p\u003e \u003cp\u003e1) Indications:\u003c/p\u003e \u003cp\u003e(1) a history of suspected VFB reported by the patient or caregivers;\u003c/p\u003e \u003cp\u003e(2) clinical manifestations and physical examination findings suggest VFB, such as abnormal vaginal discharge, foul odor, vulvar pruritus, or pain;\u003c/p\u003e \u003cp\u003e(3) imaging evidence of VFB identified by transabdominal or transperineal ultrasound.\u003c/p\u003e \u003cp\u003e2) Contraindications:\u003c/p\u003e \u003cp\u003e(1) spontaneous expulsion of the VFB with complete resolution of clinical symptoms;\u003c/p\u003e \u003cp\u003e(2) presence of acute genital tract infection;\u003c/p\u003e \u003cp\u003e(3) poor cardiopulmonary or general medical condition that precludes safe anesthesia or surgery;\u003c/p\u003e \u003cp\u003eIn cases where spontaneous expulsion of a VFB is suspected but symptoms persist, hysteroscopy was still performed to assess any residual fragments or additional VBFs.\u003c/p\u003e\n\u003ch3\u003e2. Procedures\u003c/h3\u003e\n\u003cp\u003eThroughout the entire procedure, the hysteroscope was inserted only into the vaginal canal without entering the uterine cavity. Special attention was paid to protecting the vaginal mucosa and avoiding additional trauma. Images illustrating the key procedures of hysteroscopy in this study are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The detailed steps of the procedure are as follows:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAnesthesia: All procedures were performed under general anesthesia to ensure safety and minimize discomfort.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAseptic preparation: Routine perineal disinfection and sterile draping were performed.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInsertion of the hysteroscope: The hysteroscope was gently inserted through the vaginal introitus under direct vision.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIrrigation: Sterile saline was used as the distension medium. It was introduced through the inflow channel of the hysteroscope and drained through the outflow channel, allowing for clear visualization of the vaginal walls and fornices.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDetection and removal of foreign body: Once a foreign body was identified under hysteroscopic visualization (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA), it was carefully extracted using hysteroscopic grasping forceps or biopsy forceps introduced through the working channel (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). In cases where the foreign body was large or fragmented, it was gently segmented and removed piece by piece to avoid trauma to the vaginal mucosa.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExamination of the cervix and vaginal mucosa: After the removal of the foreign body, inspect the local vaginal mucosa at the site of the removed VFB (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC), examine the cervix (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD), and subsequently check other areas of the vaginal mucosa for any residual foreign bodies or remnants (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUpon completion of the procedure, the patient was monitored until full recovery from anesthesia. The removed tissue was presented to the patient's guardian for confirmation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData was processed using SPSS version 27.0 (IBM Corp., Armonk, NY, USA) and Microsoft Excel (Microsoft Corp., Redmond, WA, USA). Categorical variables are presented as counts and percentages. The analysis of the comparative diagnostic performance of transabdominal and transperineal ultrasound was conducted with reference to the methodologies described in previous studies.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic and Clinical Features of 67 Chinese Preadolescent Girls with VFB\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e listed the sociodemographic characteristics and clinical features of 67 pediatric patients diagnosed with vaginal foreign bodies (VFB). The patients\u0026rsquo; ages ranged from 2 to 11 years, with the most common age being 6 years (23.88%), followed by ages 4 and 5 (each 13.43%). The predominant clinical manifestation was purulent vaginal discharge, observed in 50.75% of cases, followed by vaginal bleeding or blood-stained discharge (40.30%). Less common symptoms included foul-smelling discharge (10.45%), perineal redness and swelling (4.48%), genital itching (4.48%), perineal pain (1.49%), and right lower abdominal pain (1.49%). Regarding symptom duration, 38.81% of patients had symptoms lasting from one month to one year. Durations of 1 week to \u0026le;\u0026thinsp;1 month and more than one year were reported in 20.90% and 11.94% of cases, respectively. Types of VFB identified included textile materials (25.37%), unknown objects (8.96%), plastic fragments (5.97%), marbles (4.48%), nails (2.99%), stationery items such as pen caps, erasers, and pencils (2.99%), coins (2.99%), hair (2.99%), building blocks (2.99%), buttons (2.99%), paper (2.99%), and springs (1.49%). In 25.37% of cases, no foreign body was detected during hysteroscopic evaluation. Two cases involved spontaneous expulsion of the foreign body and recovery of clinical sympto prior to hysteroscopy and one patient had both hair and textile fibers identified during hysteroscopy. Pathological examination was not performed in the majority of cases (83.59%). Among the 13 cases underwent pathologic examination, findings included acute vulvitis (10.45%), chronic vulvitis (1.49%), cervical Nabothian cyst (1.49%), precocious puberty (2.99%), urethral polyp (1.49%), and vaginal polyp (1.49%). Hospitalization duration was predominantly short, with 50.75% of patients hospitalized for 2 days, and 38.81% for 1 day. Only a small proportion stayed for more than 3 days(about 10%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and Clinical Features of Girls with suspected VFB\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of cases(N\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain clinical manifestations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePurulent vaginal discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal bleeding or blood-stained vaginal discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFoul-smelling vaginal discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerineal redness and swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenital itching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerineal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight lower abdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1 day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 day to \u0026le;\u0026thinsp;1 week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 week to \u0026le;\u0026thinsp;1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month to \u0026le;\u0026thinsp;1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLonger than 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypes of VFB*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo foreign body was found under hysteroscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTextile materials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown subjects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlastic tubes or fragments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarbles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNails\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStationery items (pen caps, erasers, pencils)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuilding block\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eButtons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epaper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSprings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFindings of pathological examinations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not undergo pathological examinations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute vulvitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic vulvitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical Nabothian cyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrethral polyp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal polyp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of hospitalization(days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote:\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* There were two cases of spontaneous expulsion of the VFb\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e**Hysteroscopic examination revealed the simultaneous presence of hair and Textile materials in one case.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e***Higher medical cost due to the surgical removal of urethral polyps\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAbbreviation: VFB, vaginal foreign body\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDiagnostic performance of transabdominal ultrasound and transperineal ultrasound in the evaluation of VFB among\u003c/h2\u003e \u003cp\u003eTables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarized the diagnostic performance of transabdominal ultrasound and transperineal ultrasound in the evaluation of VFBs, using hysteroscopy as the reference standard. Representative transabdominal ultrasound photos of the VFBs were shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA\u003cb\u003e\u0026amp;B\u003c/b\u003e. Due to spontaneous expulsion of VFBs in two girls, the diagnostic performance analysis included only the remaining 65 patients who underwent both hysteroscopy and ultrasonography. For transabdominal ultrasound, the sensitivity, specificity, and accuracy were 58.3%, 41.2%, and 53.8%, respectively, based on 28 true positives, 10 false positives, 20 false negatives, and 7 true negatives. In contrast, transperineal ultrasound demonstrated improved sensitivity and overall diagnostic accuracy, with a sensitivity of 75.0%, specificity of 29.4%, and accuracy of 63.1%, derived from 36 true positives, 12 false positives, 12 false negatives, and 5 true negatives. These findings suggest that transperineal ultrasound may be more sensitive and slightly more accurate than transabdominal ultrasound in detecting VFB, albeit both modalities exhibit limited specificity.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTwo-per-two table on the performance of transabdominal ultrasound for the evaluation of VFB\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eHysteroscopy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConfirmed VFB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVFB not detect4ed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTransabdominal Ultrasound\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAbbreviation: VFB, vaginal foreign body\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTwo-per-two table on the performance of transperineal ultrasound for the evaluation of VFB\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eHysteroscopy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConfirmed VFB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVFB not detect4ed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTransperineal Ultrasound\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAbbreviation: VFB, vaginal foreign body\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummarized result of the diagnostic performance of transabdominal ultrasound and transperineal ultrasound in diagnosing VFB\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAccuracy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransabdominal Ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.583\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.412\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.538\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransperineal Ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.631\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviation: VFB, vaginal foreign body\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eVFBs in young girls are relatively uncommon in clinical practice. Due to the absence of large-scale cohort studies, accurate data on the incidence and prevalence of VFBs in the pediatric and adolescent populations remain scarce. A commonly referenced study reported a prevalence of approximately 4% among girls under the age of 13 in the United States.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e VFB are of diverse categories and often challenging to identify, particularly in pediatric patients who are unable to accurately describe or report their medical history. The limited resolution of ultrasound in distinguishing VFB frequently contributes to missed diagnosis and delayed treatment.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Most existing literature has focused on individual case reports or retrospective analyses of the clinical presentations and ultrasonographic features of VFBs.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e However, few studies have systematically compared the diagnostic performance of transabdominal ultrasound, transperineal ultrasound, and hysteroscopy. \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn current clinical practice for the diagnosis and management of VFBs, hysteroscopy has demonstrated reliable diagnostic efficacy. Previously published articles have shown a certain degree of inconsistency in the use of terms such as hysteroscopy, vaginoscopy, and vaginal endoscopy for describing similar diagnostic and endoscopic modality.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Our study involved the use of hysteroscope for vaginoscopy, also referred as vaginal endoscopy, which avoids the use of a vaginal speculum thus more suitable for treating preadolescent girls.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Under hysteroscopy, when a foreign body is identified, it can be removed during the examination. A systematic review including six randomized controlled trials(RCT) found no significant difference in diagnostic accuracy between vaginal endoscopy and conventional hysteroscopy; however, vaginal endoscopy was associated with significantly shorter procedure times and reduced patient pain.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Another systematic review and meta-analysis found that, compared to traditional hysteroscopy, vaginal endoscopy significantly reduced both examination duration and patient discomfort. Moreover, the incidence of postoperative complications was also markedly lower in the vaginal endoscopy group.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e A rigid hysteroscopy setting can be applied as the diagnostic and operative vaginal endoscopy for treating VFB, and its feasibility was demonstrated as early as 1995, when a Taiwanese team reported the hysteroscopic extraction of a VFB in a 3.5 year old girl.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In a 2007 retrospective study from Turkey, 26 women aged 17 to 54 who had preserved their virginity for religious or personal reasons were evaluated using a rigid hysteroscope. The clinicians successfully diagnosed and removed VFBs, cervical polyps, and a subserous myoma without damaging the hymen.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Recently, a case of successful vaginal endoscopic excision of the vaginal septum in a virgin girl with obstructed hemivagina and ipsilateral renal anomaly has also been reported.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e These findings collectively suggest that hysteroscopy or vaginal endoscopy can enable accurate diagnosis and effective removal of tumors or foreign bodies without compromising the integrity of the hymen.\u003c/p\u003e \u003cp\u003eThe utilization of hysteroscopy for treating VFB among young girls in China remains limited probably due to the cultural background and the conservative perception toward such invasive examinations method among Chinese guardians of the pediatric patients, which may lead to treatment delays. \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Although it was suggested that the use of smaller endoscopes could reduce invasiveness, our findings demonstrate that even with the routinely used endoscopic system in our institution, featuring an outer diameter of 10 mm, no perioperative complications were observed. Under general anesthesia, the resulting muscle relaxation allows for greater distensibility, enabling the insertion of the endoscope without damaging the hymen, including younger girls whose hymenal development is typically incomplete. Moreover, the 10 mm diameter hysteroscope offers a more spacious operative field, allowing the use of clamps for the removal of larger foreign bodies.\u003c/p\u003e \u003cp\u003eThe requirement for anesthesia and hospitalization, typically lasting one to two days, for hysteroscopic examination may further reduce parents\u0026rsquo; willingness to choose hysteroscopy as a diagnostic modality for VFB. The hysteroscopy was carefully performed without interfering the hymen. Moreover, with recent advancements in equipment and instrumentation, its invasiveness has been significantly reduced. Our evidence indicates that the diagnostic criteria for employing hysteroscopy in cases of VFBs can be appropriately broadened. Additionally, it is essential to address and modify parents\u0026rsquo; preexisting perceptions by clearly outlining the advantages, disadvantages, indications, and safety profiles of the two examination methods.\u003c/p\u003e \u003cp\u003eIn our cohort, the majority of VFBs were composed of textile fibers, hair, stationery items, and small toys. It is worth noting that textile materials and similar substances are inherently difficult to visualize on ultrasound, which we speculate may contribute to the lower sensitivity of both transabdominal and transperineal ultrasound in our study compared to findings reported in another domestic study on this issue. \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e This may also contribute to delayed diagnosis and treatment in some patients.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e In our cohort, some children experienced symptoms lasting more than one year, with one case persisting for over two years. Notably, although the overall age distribution was skewed toward younger children, those aged over 8 years still accounted for nearly one-eighth of the cohort, but obtaining accurate clinical histories from such a pediatric population was still particularly challenging.\u003c/p\u003e \u003cp\u003eDespite the use of hysteroscopy as the diagnostic gold standard, 17 children in our cohort showed no evidence of VFB upon hysteroscopic examination. However, these patients presented with clinical complaints and histories highly suggestive of VFB, and many had a prolonged symptom duration. We suspect that spontaneous expulsion of the foreign bodies may have occurred prior to the examination. Similarly, a comparable study investigating the diagnostic performance of transabdominal and transperineal ultrasound for detecting VFBs in young girls reported that approximately 40% of cases had VFB-like symptoms or a history of inserting objects into the vagina, yet no foreign body was detected upon examination.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e A recent study from Australia also reported that only 43.3% vaginoscopies yielded a positive diagnosis among prepubertal girls with vaginal discharge or bleeding.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSexual abuse is one of the causes of VFBs. However, the incidence of VFBs associated with child sexual abuse remains poorly documented. A previous literature published two decades ago reported that, in the United States, it is estimated that approximately 1% of girls are subjected to sexual violence, while around one quarter having encountered some form of inappropriate sexual behavior.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e An early retrospective case review by Herman-Giddens reported that 11 out of 12 prepubertal girls evaluated for VFBs were either suspected or confirmed victims of sexual abuse, however, none of the 67 pediatric cases included in our study were attributed to such factors. \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn general, VFBs in preadolescent girls need to be differentiated from vulvovaginitis.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e In this study, 9 cases, accounting for nearly 12% of the cohort, were involved with vulvovaginitis. Common symptoms of pediatric vulvovaginitis include vulvar erythema, pruritus, abnormal vaginal discharge, and dysuria. On the other hand, the prolonged presence of a vaginal foreign body may also lead to recurrent episodes of vulvovaginitis, particularly persistent or treatment-resistant cases in young girls. In clinical practice, diagnosis is typically established through a combination of transabdominal or transperineal ultrasonography and hysteroscopy.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe most effective approach to preventing VFB of preadolescent girls is undoubtedly to enhance supervision and cares. To reduce the risk of VFB in preadolescent girls, we propose the following measures:1) Avoid the use of open-crotch pants: In China, there has traditionally been a practice of dressing toddlers in open-crotch pants to facilitate toilet training, which has been declined significantly recently due to the widespread adoption of disposable diaper.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Open-crotch pants expose the external genitalia, increasing the risk of perineal trauma and genital infections. Additionally, they may hinder the development of children\u0026rsquo;s awareness of bodily privacy and heighten curiosity toward their genital areas, thereby increasing the risk of VFB;\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e 2) Pay attention to children\u0026rsquo;s physical and emotional well-being and promote hygiene education. Young children are curious and tend to explore their surroundings as well as their own bodies. Early education can help children understand changes in their bodies, particularly those associated with puberty, in a constructive and informed way; 4) Provide timely and appropriate sex education. Parents should help children recognize their genital organs and understand the importance of protecting their private areas. Children should be taught to refuse inappropriate physical contact, especially involving private parts, and to report any uncomfortable or suspicious interactions to trusted adults;\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e 5) Avoid behavioral imitation. For example, mothers who are administering vaginal medication should ensure that young girls are not present during the process, as such exposure may lead to behavioral imitation.\u003c/p\u003e \u003cp\u003eThis pilot study has several limitations, including a small sample size, a retrospective design, and a single-center setting, which may restrict the generalizability of our findings. However, the strengths lie in the comprehensive evaluation of the prognosis for pediatric patients with VFB that were initially missed by ultrasound, as well as the detailed assessment of clinical manifestations and their total medical cost in preadolescent patients with suspected VFB. A prospective study with a larger cohort would provide more robust evidence to guide pediatric gynecologists in selecting the most appropriate diagnostic strategies for VFB.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eUltrasound examination, including both transabdominal and transperineal approaches, demonstrates unsatisfactory diagnostic performance in diagnosing VFB. Hysteroscopy is not only the gold standard for the diagnosis of VFB but also enables the surgical removal of VFBs. Hysteroscopy should be considered the preferred modality for VFB management, but its requirement for anesthesia, hospitalization, and relatively higher medical costs may limit its acceptability among families of preadolescent patients of VFB in China.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical approval of the institutional review committee of Chengdu Women\u0026rsquo;s and Children\u0026rsquo;s Central Hospital (202566) and the 1964 Helsinki Declaration. Written informed consent for participation and publication of anonymized data was obtained from the patients\u0026apos; parents or legal guardians prior to the initiation of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is provided within the manuscript or supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was financially funded by the Japan-China Sasakawa Fellowship Program (No.4408) and the Yingcai Scheme of Chengdu Women\u0026rsquo;s and Children\u0026rsquo;s Central Hospital (No.YC2023004).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conceptualized by Dehua Wan and Tianjiao Liu. Data collection was conducted by Dehua Wan, Xiaoqi Jiang, Wenting Dong,\u0026nbsp;and Lijuan Tang. The ultrasound examinations and diagnoses were performed by Liwen Yang and Sheng Yang. Data\u0026nbsp;analyses were performed by Tianjiao Liuand Dehua Wan. The manuscript was drafted by Tianjiao Liu and Dehua Wan. Project supervision was jointly undertaken by Dehua Wan,\u0026nbsp;Tianjiao Liu,\u0026nbsp;Zhi Chen,\u0026nbsp;and\u0026nbsp;Sheng Yang. All authors contributed to the revision of the manuscript and provided final approval for its publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUmans E, Boogaerts M, Vergauwe B, Verest A, Van Calenbergh S. Vaginal foreign body in the pediatric patient: A systematic review. 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Int J implant dentistry. 2019;5(1):7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunro MG, Storz K, Abbott JA et al. AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Media: (Replaces Hysteroscopic Fluid Monitoring Guidelines. J Am Assoc Gynecol Laparosc. 2000;7:167\u0026ndash;168.). \u003cem\u003eJournal of minimally invasive gynecology.\u003c/em\u003e 2013;20(2):137\u0026ndash;148.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology. ACOG Committee Opinion, Number 800. Obstet Gynecol. 2020;135(3):e138\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBruzzone B, De Pace V, Caligiuri P, et al. Comparative diagnostic performance of rapid antigen detection tests for COVID-19 in a hospital setting. Int J Infect diseases: IJID : official publication Int Soc Infect Dis. 2021;107:215\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParadise JE, Willis ED. Probability of vaginal foreign body in girls with genital complaints. Am J Dis Child (1960). 1985;139(5):472\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa W, Sun YF, Liu JH, He DW, Lin T, Wei GH. Vaginal foreign bodies in children: a single-center retrospective 10-year analysis. Pediatr Surg Int. 2022;38(4):637\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodrigues GJ, Monteiro BM, Viana RB, da Silva AOA, Monteiro FDO, Teixeira PPM. New method of video-assisted vaginoscopy in Nellore heifers. Veterinary Med Sci. 2023;9(6):2781\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamada K, Shida D, Kato T, Yoshida H, Yoshinaga S, Kanemitsu Y. Adenocarcinoma arising in sigmoid colon neovagina 53 years after construction. World J Surg Oncol. 2018;16(1):88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhoiwal K, Zaman R, Bahurupi Y, Gaurav A, Chaturvedi J. Comparison of vaginoscopic hysteroscopy and traditional hysteroscopy: A systematic review and meta-analysis. Int J Gynaecol Obstet. 2024;164(1):47\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK\u0026uuml;\u0026ccedil;\u0026uuml;k T. When virginity does matter: rigid hysteroscopy for diagnostic and operative vaginoscopy\u0026ndash;a series of 26 cases. J Minim Invasive Gynecol. 2007;14(5):651\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamada Y, Kawaguchi R, Iwai K, Waki K, Kawahara N, Kimura F. Successful vaginoscopic excision of the vaginal septum in a virgin girl of obstructed hemivagina and ipsilateral renal anomaly: Case report and review of literature. J Obstet Gynaecol Res. 2023;49(1):350\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKellogg N. The evaluation of sexual abuse in children. Pediatrics. 2005;116(2):506\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerman-Giddens ME. Vaginal foreign bodies and child sexual abuse. Arch Pediatr Adolesc Med. 1994;148(2):195\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeyitler İ, Kavukcu S. Clinical presentation, diagnosis and treatment of vulvovaginitis in girls: a current approach and review of the literature. World J pediatrics: WJP. 2017;13(2):101\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLukowski AF, Liu X, Peirano P, Odio M, Bauer PJ. Disposable diaper use promotes consolidated nighttime sleep and positive mother-infant interactions in Chinese 6-month-olds. J family psychology: JFP : J Div Family Psychol Am Psychol Association (Division 43). 2015;29(3):371\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"vaginal foreign bodies, hysteroscopy, vaginal endoscopy, transabdominal ultrasound, transperineal ultrasound, preadolescent girls, vaginal discharge, vaginal bleeding","lastPublishedDoi":"10.21203/rs.3.rs-6769599/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6769599/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eVaginal foreign body (VFB) is an uncommon but clinically important condition in preadolescent gynecology. Timely diagnosis and removal of VFB are essential to prevent complications such as infection, ulceration, and long-term reproductive sequelae. While the use of hysteroscope for vaginoscopy is considered the diagnostic gold standard and enables the surgical removal of the VFB, ultrasound remains more widely used due to its non-invasive nature, low cost and convenience. However, the application of hysteroscopy in the diagnosis and treatment of VFBs in China remains relatively limited due to cultural and socioeconomic factors, as well as anesthesia-related risks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis retrospective study included 67 pediatric patients with clinically suspected or hysteroscopically confirmed VFBs treated at Chengdu Women’s and Children’s Central Hospital from January 2011 to February 2025. Clinical data were collected, including patient age, symptoms, symptom duration, type of foreign body, pathological findings, hospitalization duration. The diagnostic performance of transabdominal and transperineal ultrasound was compared, using hysteroscopy as the reference gold standard.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong the 67 cases, the most common symptoms were vaginal discharge and bleeding. Textile fibers, hair, and small toys were the most frequently identified VFBs. Transabdominal ultrasound demonstrated a sensitivity, specificity, and accuracy of 58.3%, 41.2%, and 53.8%, respectively. Transperineal ultrasound showed improved sensitivity (75.0%) and accuracy (63.1%) but similarly limited specificity (29.4%). Hysteroscopy facilitates both diagnosis and direct removal of VFBs while avoiding injuring the hymen. Despite its advantages, barriers to hysteroscopy included the need for anesthesia and hospitalization, which may affect parental acceptance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eUltrasound, although commonly used, exhibits poor diagnostic performance in detecting VFB in preadolescent girls. Hysteroscopy, with its superior accuracy and therapeutic capability, should be more preferably considered as diagnostic and treatment modality.\u003c/p\u003e","manuscriptTitle":"Should Hysteroscopy Be More Preferably Employed for Treating Vaginal Foreign Bodies in Preadolescent Girls?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-30 08:47:54","doi":"10.21203/rs.3.rs-6769599/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aed598d3-730c-4ec5-822a-e8e7079a2842","owner":[],"postedDate":"June 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-28T09:42:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-30 08:47:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6769599","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6769599","identity":"rs-6769599","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}