Case 35: Vulval swelling

 

Case 35: Vulval swelling

CASE 35: VULVAL SWELLING

History

A 17-year-old girl presents with a vulval swelling. She noticed a lump a few weeks earlier

and in the last 2 days it has enlarged and become painful. She cannot walk normally and

has not been able to wear her normal jeans because of the discomfort. She feels well in herself however.

She has been sexually active since the age of 14 years and uses the depot progestogen injection

for contraception and therefore does not have periods. She has been with her boyfriend for

8 months and on direct questioning reports unprotected intercourse with two other boys in

that time. She had a sexual health screen in a genitourinary clinic 1 year ago and the result

was normal. There is no other medical history of note and she takes no medication.

Examination

The temperature is 37.7°C, heart rate 68/min and blood pressure normal. Abdominal examination is normal. There is a left-sided posterior labial swelling extending anteriorly from the

level of the introitus, measuring 6 × 4 × 4 cm. It appears red, fluctuant, tense and is exquisitely

tender to touch. Left-sided tender inguinal lymph nodes are noted.

Questions

• What is the diagnosis?

• How would you manage this patient?100 Cases in Obstetrics and Gynaecology

86

ANSWER 35

The diagnosis is of a Bartholin’s abscess. The Bartholin’s glands are located in the posterior

vulva and the gland ducts open into the lower vagina to maintain a moist vaginal surface,

important during intercourse. Obstruction to a duct by inflammation (from friction during

intercourse) or infection causes a cyst to develop, which commonly becomes infected. Usually

mixed flora is found but in 20 per cent of cases gonorrhoea is isolated.

The diagnosis is clinical and it is important to differentiate a Bartholin’s cyst from the differential diagnosis of a sebaceous cyst, vaginal wall cyst or perianal abscess.

Management

The abscess must be drained, traditionally by formal incision and drainage, with the edges of

the cyst capsule sutured to the skin to prevent reclosure of the duct (marsupialization).

Increasingly commonly to avoid general anaesthetic, an inflatable balloon catheter (‘Word

catheter’) is inserted into the abscess (or cyst) under local anesthetic to drain the fluid. This is

left for 4 weeks, to allow epithelialization and a long-term drainage route for the gland, thus

hopefully reducing the chance of recurrence of the abscess.

In this case the girl has had several recent partners and a general sexually transmitted infection screen should be arranged after drainage of the cyst, with general sexual health advice.

In most cases antibiotics are not needed after drainage unless there is significant surrounding

erythema, systemic signs of sepsis, inguinal lymphadenopathy (as in this case) or gonococcus

is found in the culture of the drained fluid.

KEY POINTS

• Bartholin’s abscesses are relatively common and cause acute painful unilateral

vulval swelling.

• Drainage of the abscess and marsupialization of the skin edges are the mainstay of

treatment but recurrence is still common.

• Pus should always be sent for culture as gonorrhoea is isolated from up to 20 per

cent of Bartholin’s abscesses.