Case Study Reports: Vulval Swelling

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 her- self however.

She has been sexually active since the age of 14 years and uses the depot progesterone 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. Bilateral tender inguinal lymph nodes are noted.

Questions

·             What is the diagnosis?

·             How would you manage this patient?

ANSWER

The diagnosis is of a Bartholin’s abscess. The Bartholin’s glands are located in the pos- terior 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 fric- tion 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 dif- ferential 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). Alternatively a Word catheter can be inserted for 4 weeks, which acts to allow continued abscess drainage and encourage epithelialization of the tract to provide a long-term drainage route for the gland. In most cases antibiotics are not needed after drainage, unless there is surrounding erythema or systemic signs of sepsis are present.

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. She should also be advised that Bartholin’s abscesses may recur, even after marsupialization.