Vulvar Abscess, Skene's Gland Abscess, Bartholin's Abscess S. Paige Hertweck MD Basics Descri tion Dee tissue in!

ections o! the vulva" #$ icall$ occur within con!ines o! labia %a&ora Bartholin's glands abscesses %ore co%%on than ri%ar$ labial abscesses

Periclitoral abscesses si%ilar to other vulvar abscesses e'ce t in location.

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(esions thought to be ericlitoral abscesses %ust be di!!erentiated !ro% ilonidal c$sts arising in ericlitoral region that will re)uire co% lete surgical e'cision instead o! incision and drainage.

Skene's gland * eriurethral gland+ abscesses are unco%%on, eriurethral in location and when ver$ enlarged can cause labial enlarge%ent

Age,-elated .actors Bartholin's abscess" /suall$ resents ages 01203 -are a!ter age 41, resence at that age sus icious !or %alignanc$ and re)uires bio s$ and5or co% lete e'cision 6 ide%iolog$ Most in!ections are related to aerobic and anaerobic organis%s co%%onl$ seen in the vaginal and cervical !lora 7o%%unit$,ac)uired %ethicillin,resistant Sta h$lococcus aureus *M-SA+ is an increasingl$ seen athogen in labial abscesses es eciall$ in children

Bartholin's abscesses t$ icall$ have both anaerobic and aerobic organis% on culture but also have association with gonorrhea and chla%$dia.

-isk .actors Most cases occur without redis osing risks but redis osing !actors include" o Diabetes
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Pregnanc$ #rau%a *e.g., scratching, shaving+ Previous i% etigo

7o%%unit$,ac)uired %ethicillin,resistant Sta h$lococcal aureus labial abscesses %a$ be due to"
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Shared athletic e)ui %ent Shared ra8ors .a%il$ %e%bers with M-SA

Genetics 9o genetic attern

Diagnosis Signs and S$% to%s Histor$ (ocali8ed ede%a, er$the%a and ain o! the labia Histor$ o! vulvar abrasion, in&ur$ or trau%a
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9ot alwa$s elicited

Histor$ o! re,e'isting e ider%al inclusion c$st Possible !ever

-eview o! S$% to%s Der%atologic conditions" 6c8e%a or histor$ o! i% etigo Ph$sical 6'a% :5, .ever (ocation o! abscess"
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#rue labial abscess"

/nilateral, tender, swollen, er$the%atous labia

Bartholin's abscess"

7$stic ain!ul swelling o! the osterior labia in the area o! the Bartholin's gland *at ;"11 or <"11 osition o! vagina introitus+

Skene's abscess"

Swelling at the anterior vagina &ust beneath the urethra

/rinar$ s$% to%s"

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/rgenc$ .re)uenc$ D$suria Post%icturition dribbling

Possible labial discharge i! ru tured

#ests Bartholin's gland abscesses have been associated with chla%$dia and gonorrhea in!ections (ab #est urine or endocervi' !or chla%$dia and gonorrhea =%aging 9o i%aging indicated Di!!erential Diagnosis =n!ection 7ellulitis 9ecroti8ing !asciitis

#u%or5Malignanc$ =n wo%en >41 $ears, consider bio s$ !or Bartholin's gland %alignanc$ ?ther5Miscellaneous Mesone hric c$st o! the vagina (i o%a

.ibro%a Hernia H$drocele 6 ider%al inclusion c$st 9euro!ibro%a Aberrant breast tissue

#reat%ent General Measures Pain relie! will occur with drainage o! us o S ontaneous
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Surgical

@o%en with abscesses alread$ with a A ointB or that ru ture s ontaneousl$ %a$ re)uire onl$ sit8 baths, not antibiotics. /se war% sit8 baths or hot acks to bring abscess to a A ointB then roceed with incision and drainage i! s ontaneous ru ture does not occur

P.0CD Medication *Drugs+ #reat with s$ste%ic antibiotics" o 7over both aerobic and anaerobic bacteria
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9eed sta h aureus coverage based on local sensitivitiesEconsider use o! clinda%$cin as initial thera $

=! unru tured"
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=nitiate broad,s ectru% antibiotics *C dose 7e!tria'one C0; %g =M lus clinda%$cin D11 %g P? ).i.d. !or < da$s+ to cover skin bacterial !lora, anaerobic bacteria and ossibl$ gonorrhea and chla%$dia *e.g., 7e!tria'one C0; %g lus clinda%$cin D11 %g ).i.d. !or < da$s ?o!lo'acin 411 %g B=D and .lag$l ;11 %g b.i.d. !or < da$s+ Draw a line on the skin surrounding the abscess to delineate the !urthest e'tent o! in!la%%ator$ change. =! %argins rogressEconsider ossibilit$ o! necroti8ing !asciitis

S ecial #hera $ 7o% le%entar$ and Alternative #hera ies Give a single dose intrao erative clinda%$cin #hen !ollow with incision, curettage and ri%ar$ suture under general anesthesia.
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6' ose abscess cavit$ and curette lining, Pass interru ted ol$ ro $lene sutures beneath but not through the cavit$ and close the de!ect. -e%ove sutures on Fth osto erative da$.

Sclerothera $"
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A!ter incision and drainage, lace cr$stalloid silver nitrate stick 1.; c% in length and dia%eter laced into cavit$. Patient %a$ e' erience %ild burning.

.ollow,u in 4G hours to clean wound.

Surger$ Bartholin's abscessE#reat in 6D or o!!ice" o A!ter in!iltrating with local anesthetic, %ake stab incision over thinnest %ost %edial as ect o! abscess * re!erabl$ at or behind the h$%enal ring+"

6vacuate abscess cavit$ Gentl$ robe !or loculations Place @ord catheter *a short catheter with an in!latable .ole$ balloon+ into abscess cavit$ and !ill bulb with saline #uck end o! catheter inside vagina to %ini%i8e disco%!ort (eave @ord catheter in lace !or at least 024 weeks to ro%ote !or%ation o! an e itheliali8ed tract !or drainage o! glandular secretions.

Marsu iali8ation with creation o! larger o ening than stab wound as alternative %anage%ent 6'cision o! gland reserved !or recurrent cases unres onsive to other treat%ent %odalities Skene's abscess =! s ontaneous drainage does not occur or recurs, e'cision and correction o! ossible coe'isting urethral diverticulu% is re)uired

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General anesthesia %a$ be re)uired"

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=n a child or adolescent

=! ain recludes in o!!ice =HD

.ollowu Dis osition =ssues !or -e!erral 7onsultation or re!erral i! necroti8ing !asciitis sus ected" High %ortalit$ rate @ide debride%ent and e'cision re)uired Prognosis -ecurrence o! Bartholin's abscess not rare a!ter initial gland abscess and da%age o! gland ori!ice -ecurrence less likel$ with use o! @ord catheter than with si% le incision and drainage, as e itheliali8ed tract is established. Patient Monitoring .ollow,u to %onitor !or s ontaneous drainage or the need !or surgical intervention and5or recurrence. Bibliogra h$ .aro S. P$ogenic conditions o! the vulva. =n" Iau!%an -H, et al., eds. Benign Diseases o! the Vulva and Vagina. ;th ed. Philadel hia" Mosb$J 011;"0F420FF. (arsen #, et al. #reat%ent o! abscesses in the vulva. Acta ?bstet G$necol Scand. C3GFJF;"4;324FC. Kuce I, et al. ?ut atient %anage%ent o! Bartholin gland abscesses and c$sts with silver nitrate. Aust 9 L M ?bstet G$naecol. C334JD4"3D. Miscellaneous 7linical Pearls N (abial abscesses that start initiall$ as a a ule and ra idl$ e' and into a large abscess over 04 hours are highl$ suggestive o! M-SA and re)uire i%%ediate antibiotic coverage and incision and drainage. N -ecurrent ericlitoral abscesses re)uire co% lete e'cision and bio s$. 2 Ma$ be secondar$ to resence o! ilonidal c$st Abbreviations M-SAEMethicillin resistant sta h$lococcus aureus 7odes =7D3,7M N ;3<.1 Skene's gland abscess N FCF.D Bartholin's gland abscess N FCF.4 Vulvar abscess Patient #eaching 9eed !ollow,u to %onitor !or s ontaneous drainage or need !or intervention !or recurrence Prevention -educe e' osure to S#Ds and vulvar trau%a *i.e., scratching, shaving+