Case 3 A 23-year-old woman admitted as an emergency with acute vulval pain

 Case 3 A 23-year-old woman admitted as an

emergency with acute vulval pain

Chloë White is 23 years old and presents with rapid onset of

vulva pain. She was aware of some discomfort and

tenderness the previous 2 days and noticed a swelling on

the left side of her vulva when in the shower. The pain is

now unbearable. She has taken paracetamol with no

noticeable relief. At first she hoped it would settle on its

own. She was embarrassed to be seen but now she cannot

sit because the swelling is so tender.

What differential diagnoses

immediately comes to mind?

• Bartholin ’ s abscess

• Vulva abscess

• Genital herpes

• Vulva haematoma

• Beh ç et ’ s disease

• Thrush infection

• Contact dermatitis

What would you like to elicit from

the history?

With this presentation of acute pain, you need to make

a provisional diagnosis. History - taking will allow you to

develop a rapport with the patient before your examination. Examination will be revealing, help direct any

further detailed questions and, importantly, allow you to

make a provisional diagnosis so you can instigate pain

relief.

You need to consider sexually transmitted infection

(STI) but, in your initial history, you do not need to take

a full sexual history. You should ask about recent sexual

contact, use of contraception, previous episodes of vulva

pain or discharge. You also need to clarify if she has taken

any medications and if these preceded the development

of her symptoms. You should ask about any possible

topical irritants including washing and sanitary products

and clothing. You should ask about any possible trauma.

If she has been assaulted, she may not offer this information initially. With a primary herpes infection, she may

have generalized symptoms of malaise, myalgia, headache and fever.

Chloë tells you that she has one regular sexual partner and

has a contraceptive implant for the last 2 years. She does

not use any barrier methods. She has no history of thrush or

STIs. The only medication that she has taken is paracetamol

since the pain started. She has very light periods with the

implant but her last menstrual period (LMP) was 3 weeks

previously and she has not used any sanitary products. She

uses a shower gel and wears cotton ‘boy shorts’ type

underwear.

What would you look for on

physical examination?

General examination

There may be little or nothing to find on general examination. She is unlikely to have any systemic signs of infection. If you were considering a drug eruption or Beh ç et ’ s

disease, you need to check her oral mucosa for signs of

ulceration. If she has a Bartholin ’ s abscess or herpes

infection, she may have inguinal lymphadenopathy.

Pelvic examination

You need to make a visual inspection of her vulva but

you must explain exactly what you intend to do as she is

in considerable pain. It may not be possible to do more

than an inspection so make sure that you have an adequate light source as this should lead you to the diagnosis.

There is no indication to do an internal examination at

this stage and she would be unable to tolerate this

procedure.

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.Case 3 39

PART 2: CASES

To summarize your findings so far, Chloë is a 23-year-old

para 0+0 with 48-hour history of increasing vulva swelling

associated tenderness and pain. On examination, she has an

erythematous tender swelling localized to the left side of her

posterior fourchette. The swelling has surrounding

induration and she has a tender lymphadenopathy in her left

inguinal region.

What do you do next?

You do not need to obtain any further investigations at

this stage. She has a Bartholin ’ s abscess and you should

assess her for an anaesthetic and book her for emergency

surgery (Box 3.1 ; Fig. 3.1 and Fig. 3.2 ).

What surgical procedure is necessary?

Marsupialization of Bartholin’s abscess

The underlying pathology is blockage of the duct draining from the Bartholin ’ s gland. Simple incision and

drainage will not allow the duct to drain so marsupialization is performed. An ellipse of overlying vaginal mucous

is excised along with the abscess wall to allow the pus to

drain. The edges are sewn together with an interrupted

dissolvable suture to maintain patency. Postoperatively

this will reduce to a tiny opening.

Now review your differential diagnosis

Vulva abscess

Although your examination findings confirm an abscess,

the anatomical site clinches the diagnosis. A vulval

abscess is more likely to be found in the hair - bearing skin

of the labia majora or mons pubis arising in hair follicles,

sweat glands or sebaceous glands. Anyone can develop a

skin abscess but this can be associated with diabetes.

These are treated by incision and drainage. In hydradenitis suppurativa, a disorder of the sweat glands, multiple

small abscesses and scarring are found in the anogenital

and axillary areas. This often starts in teenagers or young

adults and is more common in women.

Herpes virus infection

A primary herpes virus infection (HSV) can be extremely

painful and require hospital admission. The pain is bilateral and generalized. Chlo ë does not have risk factors for

HSV (number of sexual partners or previous history of

STIs) although she does not use barrier contraception.

Genital herpes usually presents 2 – 14 days after sexual

contact. Admission may be necessary in the case of secondary urinary retention requiring catheterization.

On examination, you would expect to see multiple

papules, vesicles or shallow ulcers with associated

Box 3.1 Bartholin’s gland

There are two Bartholin’s glands situated on either side of

the posterior fourchette. The duct from each gland drains

into the lower vagina between the hymenal remnants

(carunculae myrtiformes) and the fourchette. Blockage of

the gland can result in a mucous retention cyst which can

grow to 3–5cm in diameter and presents as a vuval

swelling. Infection results in an abscess which presents

with pain. This is seen more often than a cyst.

(a) (b)

Figure 3.1 (a) Site of Bartholin’s gland and duct and (b)

marsupialization of a Bartholin’s abscess.

Figure 3.2 Bartholin’s abcess.40 Part 2: Cases

PART 2: CASES

erythema, oedema and crusting. A swab should be taken

to confirm the diagnosis and allow counselling on future

recurrence. However, if you suspect herpes you should

start antiviral therapy immediately with aciclovir 400 mg

three times per day for 7 – 10 days for an primary episode.

If she is in acute urinary retention, she will have severe

lower abdominal pain and a tender distended bladder

will be palpable on abdominal examination. This complication may be caused by inhibition secondary to pain,

local swelling or neuropathic from nerve root involvement. You may have to insert a suprapubic catheter.

Topical anaesthetic gel can be useful for pain relief. You

need to arrange follow - up at genitourinary medicine

(GUM) clinic to screen for other STIs.

Vulva haematoma

Haematoma is related to trauma and is seen more commonly following childbirth but it is also seen following

accidental injury (e.g. straddle injury) or non - accidental

injury where internal penetrative injuries to other structures (e.g. bladder, bowel and vagina) need to be excluded.

It is also a complication of vaginal surgery if a haematoma forms below the level of the pelvic floor and blood

tracks down the loose tissue planes into the vulva and

buttock. Haematomas cause a tender swelling and the

blood causes discoloration which is obvious in association with a history of trauma.

Haematomas are self - limiting and can be managed

conservatively with pain relief, catheterization and blood

transfusion if necessary. If large, you may consider exploration and drainage. As bleeding is often from the venous

plexus rather than arterial, no obvious bleeding points

may be found after evacuation of haematoma and you

may need to leave in a drain to avoid reaccumulation.

Trauma above the level of the pelvic floor (pelvic or

vaginal surgery, childbirth or penetrating injury) will

not track down to the vulva so there are no external

findings.

Behçet’s disease

This is a chronic autoimmune disorder with recurrent

episodes of mouth ulcers. It can be associated with vulva

ulceration. Autoimmune disorders tend to present for

the first time in young women and this condition is more

common in women presenting for the first time aged

20 – 40 years. There is no diagnostic test and other conditions, especially herpes, need to be excluded. A fixed drug

eruption can present with a similar appearance of vulva

redness and swelling and blistering which is extremely

painful. It starts within minutes or hours of taking

the precipitating medication and can be caused by

paracetamol or ibuprofen. Chlo ë gives no preceding

history of drug - taking or previous episodes of mouth

ulcers.

Thrush infection

Vulva candidiasis can cause inflammation, excoriation

and pain as well as itch. However, it does not develop

rapidly as in this case nor be severe enough to require

admission. On examination, there may be bilateral erythema and inflammation with a leading edge or satellite

lesions. This can require a prolonged course of topical

antifungal therapy to clear.

Contact dermatitis

Chlo ë gives no obvious history of contact irritants. Swelling and erythema would be bilateral involving the area

in contact with the sensitizer. Dermatitis is more likely

to cause itch with pain secondary to irritation and itching

damaging the skin.

On recovery from her anaesthetic, Chloë feels much better

and is able to be discharged later the same day. A swab

taken from the abscess in theatre grows mixed anaerobes.

Antibiotics are only required if there is an associated

cellulitis. She may develop another Bartholin’s abscess in the

future but the recurrence rate is low so no follow-up is

required.Case 3 41

PART 2: CASES

CASE REVIEW

Women with severe vulva pain may be admitted as an

emergency to the gynaecology ward. Occasionally, this is

caused by uncommon dermatological conditions (Beh ç et ’ s

disease, fixed drug eruption, pemphigus) and liaison with

the dermatology department is essential.

However, there are a few common gynaecological

causes for this symptom. Bartholin ’ s abscess is often

seen but may also be referred to the outpatient clinic

as a Bartholin ’ s cyst. The diagnosis is obvious on clinical

examination because of its anatomical location. Pain relief

will be obtained by draining the abscess so theatre needs

to be booked. While waiting to go to theatre, you should

provide adequate analgesia and a hot bath may help. It is

necessary to marsupialize the abscess rather than simple

incision and drainage which has a higher risk of recurrence as the gland duct remains blocked. The usual causal

organisms are mixed anaerobes, but occasionally there

can be a specific organism such as gonorrhoea or chlamydia so a swab should be taken from the abscess in

theatre.

In this age group, a primary HSV infection is likely and

may be associated with considerable erythema and oedema.

However, this will be generalized and bilateral. It may

result in urinary retention and you may need to use a

suprapubic catheter to relieve the retention. There may

also be systemic symptoms of malaise, fever and myalgia.

Recurrence is common but future attacks tend to be less

severe and aciclovir should be taken as soon as any prodromal symptoms are experienced to lessen the severity

and duration of the attack.

Vulva haematoma will be obvious on examination.

There will be a history of a straddle type injury with bleeding arising from the rich venous plexus of the vulva or a

penetrating injury to the vagina with tracking of blood

downwards. With vaginal lacerations, you will need to

examine the patient under anaesthetic to identify any

injury to bladder, bowel or perforation of the peritoneum

and suture any vaginal lacerations. If there is no clear

history of trauma, you need to consider non - accidental

injury.

KEY POINTS

• Acute vulva pain is a common emergency admission to

the gynaecology department

• Women are often in considerable pain so you need to

provide analgesia promptly

• The diagnosis can usually be made on inspection and your

examination may be limited to this aspect only if the

woman is in pain

• Bartholin’s abscess is common and is diagnosed by the

anatomical site of the abscess

• Bartholin’s abscess requires marsupialization to allow the

gland to drain and reduce the risk of recurrence

• If you suspect HSV, you need to instigate management

before you have swab results available

• If HSV is confirmed, you need to arrange follow-up at

GUM for counselling and a full STI screen

• Vulva haematomas can often be managed conservatively

but exploration is required if they are increasing in size or

if they result from a penetrating injury