What's Your Diagnosis? Sharpen Your Physical Diagnostic Skills

June 1, 2008

A 27-year-old primigravida is seen 3 weeks before expected date of confinement, with a 1-week history of vulvovaginal pain and a yellowish white discharge.

HISTORY
A 27-year-old primigravida is seen 3 weeks before expected date of confinement, with a 1-week history of vulvovaginal pain and a yellowish white discharge. These symptoms have worsened despite use of a topical antifungal. No history of sexually transmitted disease.

PHYSICAL EXAMINATION
Woman in moderate pain and psychic distress, worried both about herself and about any possible effect on her baby. No fever. General examination appropriate for stage of gestation. No rashes or enanthems. As shown, left labium majus is deformed, whereas right appears normal.

The right labium majus provides a convenient point of comparison: its skin is wrinkled and is demarcated posteriorly from skin abutting the posterior fourchette and the perineal body. Some darkening of the latter skin appears to be not extrinsic staining, but rather the common darkening of genital and perineal skin seen in both sexes, which is sometimes heightened during pregnancy.

By contrast the left labium is red, shiny, and swollen; inflammation has effaced the normal labial contours, which have been replaced by a vertical red structure that extends from the region of the clitoral hood-marked by the distal (inferior) extent of the dense pubic hair-to beyond the ordinary landmark, encroaching past the perineal body onto the region of the anus. On palpation, this swelling was very tender, and the diagnosis of Bartholin cyst with secondary infection, constituting Bartholin gland abscess, was made.

SHOULDN'T WE SEE A MASS? OR AN INFLAMED, OBSTRUCTED ORIFICE?
Although swelling can be discerned, it looks more cellulitic, rather than forming a distinct mass. Part of the issue is that the gland points inward, its orifice lying in the vaginal vestibule; a considerable amount of loose connective tissue as well as the bulbospongiosus muscle separates the gland from the skin surface, effectively blanketing the inflammation but not attenuating the sharp pain it causes. Use of ultrasound technology has provided further insight about the internal anatomy of this process.1

Even when a mass is more conspicuous (Figure), it may appear to be partially intravulvar and partially lateral, and erythema may be sparse or even absent.


The orifice is not well seen unless, at a minimum, the labia minora are spread manually during examination-something easily accomplished by inspection on a hospital bed or an examining table, for the patient who cannot readily assume lithotomy position. Of course, the orifices can also be visualized with a vaginal speculum in place. Inference of the inflammatory process, and of the infection that causes it, are key elements in bedside recognition of Bartholin abscess.

HOW DANGEROUS?
Some clinicians may regard Bartholin abscess as a purely local problem, but cases of septic shock have occurred,2,3 one of them after self-manipulation in an attempt to drain the abscess ("squeeze the pimple"). This yet again demonstrates the stupidity of trying to expel infected material without proper medical means, ensuring the microbes access to additional local tissue, lymphatics, and capillaries with the potential for seeding the bloodstream.

Rarely, cases treated conventionally have led to bacteremias, including some caused by uncommon variants of Streptococcus milleri4 and even Brucella species.5 Very rarely, necrotizing fasciitis has occurred6 (necrotizing perineal infection); this is not surprising given the bacteriology and the analogous sequence in the male in whom Fournier gangrene develops.7IS BARTHOLIN GLAND ABSCESS AN STD?
Certainly a prime risk factor for bartholinitis is injury and swelling of the distal duct and its orifice, and trauma from sexual intercourse can play a part. Surprisingly, surgery that might damage the region appears to produce only a small number of cases.8

Cultures of the pus from Bartholin abscesses have yielded a variety of organisms, with wildly differing percentages depending on the methodology of the individual study.9 Gram-negative organisms are frequent, and so are anaerobes and facultative microaerophiles. Neisseria gonorrhoeae is found about 10% of the time. Chlamydia trachomatis has been implicated in a small subset of cases, but the principal study showed marked methodological flaws, which is not to say its conclusions are incorrect10; similar comments apply to a paper on whether Bartholin abscess carries excess epidemiologic risk of seropositivity for HIV.11

Just in case this were too straightforward, other conditions have mimicked Bartholin abscess, among them advanced Kaposi sarcoma of the vulva12 and idiopathic granulomatous vulvitis,13 a condition akin to some genital manifestations of Crohn disease and to the idiopathic granulomatous cheilitis discussed in a prior column in these pages.14

In brief, sexual intercourse is a common but not inevitable antecedent, whether or not non-STD pathogens are in fact transmitted in this fashion. Although pregnancy is a weak risk factor, most pregnancies are not complicated by bartholinitis, so it is difficult to attribute risk to the major local anatomical and functional changes that occur in pregnancy.

THERAPEUTIC APPROACHES: A LONG LIST
A great many methods have been utilized to treat Bartholin abscesses and cysts. All seek maximal ease and convenience with highest primary cure rate, fewest recurrences, eventual restitution of the most normal anatomy possible, prevention of persistent dyspareunia after the briefest treatment interval, and, when feasible, avoidance of general anesthesia.

Instillation of alcohol has been used,15 as has topical silver nitrate,16 and also insertion of a cathether into the cyst cavity to create an epithelialized fistula17; such fistulas have also been constructed surgically.18 The old standbys of marsupialization and plain incision and drainage remain in use.

WHAT ABOUT THE BABY?
Mother and child both did well: the abscess was incised and drained, antibiotic therapy appropriate during pregnancy was given, analgesia was prescribed, and 2 weeks later she had normal spontaneous vaginal delivery of a healthy boy.

 

References:

REFERENCES:


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3. Honig J. Septic shock complicating drainage of a Bartholin gland abscess. Obstet Gynecol. 1991;77:490.
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