Thakare R*, Thosar MA**, Gupta AS***
(*First Year Resident, **Assistant Professor, *** Professor, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India.)
A pregnant woman at 34 weeks of pregnancy was referred to our tertiary care hospital with extensive abscess of the vulva extending to the groin and anterior abdominal wall for management. The abscess was incised and drained under antibiotic cover. Daily dressing with collagen granules and silver colloid gel was done. She had premature rupture of membranes on second day of procedure and delivery was conducted by lower segment cesarean section (LSCS) for fetal distress. The wound healed over a period. The fetal outcome was uneventful.
Simple infections of the vulvar skin and subcutaneous tissue can result in the formation of a vulvar abscess which is a common problem seen in gynecological practice. The loose areolar tissue present in the subcutaneous layers of the vulvar area along with the contiguity of vulvar fascial planes with the groin and anterior abdominal wall facilitates the spread of infection and abscess formation.
A 22 year old primigravida married since one year, with 34 weeks of gestation was referred from a peripheral hospital to our tertiary care hospital in view of large left sided vulvar abscess extending to the anterior abdominal wall and inguinal region for incision and drainage. She had a swelling in the vulvar area since seven days. Initially swelling was about 1x1cm and had increased gradually. She also complained of pus discharge from the lesion and fever since one day. She had difficulty in walking and had a wide based gait. She was admitted in a private hospital, where she received parenteral antibiotics for four days. She was referred to a higher center due to non-resolution of the abscess. She had no bowel or bladder complaints. She had no history of tuberculosis, hypertension, diabetes mellitus, asthma, thyroid disorder or epilepsy. There was also no history of any surgical illness, blood transfusion or drug allergies. Ultrasound (USG) was done of the local perineal region. It showed a heterogeneous collection of 3.4×1.8 cm in the left vulvar region extending to the mid-inguinal region as well as to the left medial and anterior aspect of the thigh. Right inguinal region showed a single enlarged lymph node measuring 1.8 cm. On admission her general condition was fair and she was afebrile. Pulse was regular, good volume, she had no tachycardia. Blood pressure was in the normal range. No cardiovascular or respiratory abnormality was detected. Bilateral pedal edema was present up to the knees. On abdominal examination uterus was 34 weeks in size, relaxed, fetus was in vertex presentation, head was 4/5th palpable and fetal heart sounds were present, regular in rhythm with a rate of 140 beats per minute. On local examination left sided lower abdominal wall erythema and induration with warmth on touch, extending to the left labia majora was seen and felt. Excoriation was present over the left labia majora. A spontaneous sealed site of pus drainage was seen over the left labia majora. Swelling and induration was also extending to the medial side of the groin and thigh. No midline extension of the swelling was noted. Right sided labia majora and minora were normal. No enlarged lymph nodes were palpable on either side. (Figure 1)
Figure 1. Abscess of the left labia majora extending to the medial side of the groin and thigh.
The swelling was extremely tender, and she was not co-operative. She could not flex her left leg as the limb muscles were in spasm. Her hematological, serological and biochemical parameters were normal. Her HIV status was also seronegative. General surgeons were consulted and a joint decision to drain the abscess was taken. After preoperative workup and consent incision and drainage of the vulvar abscess was done under spinal anesthesia. Three incisions were taken (Figure 2). The 1st incision was over the left labia majora on the most prominent fluctuant and dependant site. Second and 3rd incisions were taken over the left inguinal region and all pus was drained out. Blunt dissection was extended to the medial side of the thigh. All the pus was drained out; all loculi were broken by blunt dissection. Thick, yellow and foul smelling pus was collected and sent for aerobic, anaerobic and AFB cultures (Figure 3). Broad spectrum parenteral antibiotics were continued. No biopsy was taken as there was no clinical suspicion of malignancy.
Figure 2. Surgical incisions.
Figure 3. Pus drainage.
The abscess cavity was irrigated with hydrogen peroxide, povidone iodine and warm saline. The abscess cavity was packed with povidone iodine soaked gauze pieces and covered with sterile dressing. Both the preliminary and final reports of pus culture were suggestive of no growth. Next day she had premature rupture of membranes. Preinduction cervical ripening was done with Dinoprostone gel. The Bishop’s score failed to improve. Fetal distress was noticed on intrapartum monitoring. A decision of emergency lower segment cesarean section was taken after explaining risk of peritonitis to her and her relatives. The cesarean section was done by vertical midline incision over the abdominal wall after isolating the abscess area to prevent the spread of infection by contiguity. Maternal and fetal outcome were good. Baby’s birth weight was 2.269 kg with APGAR score of 9/10. In the neonatal period, the baby had no signs and symptoms of sepsis.
Post operatively daily dressing of vulvar wound was continued. The vulvar wound healed but the communicating wound at the groin had a wide defect as the she was ambulatory Plastic surgeons reviewed the gaping wound in the left inguinal region. A 3x3 cm fistulous tract was present with signs of inflammation. Daily sitz bath and irrigation of the fistulous tract with vinegar from the upper end to lower end and regular cleaning and dressing with silver colloid gel and collagen granules was advised. Plan of primary closure with debridement followed by split thickness skin grafting was made. However the wound continued to heal. The plastic surgeons reviewed the wound and the decision of grafting was canceled. Daily cleaning and dressing of the wound was continued. The abdominal incision of the cesarean section healed well. On discharge, the vulvar wound was healed, but the wound at the left inguinal region was present for which daily dressing was advised with collagen granules. On follow up with the plastic surgeons, the wound was better and was healing.
Hair follicles, sweat and sebaceous glands of the vulvar skin are common sites of infection and abscess formation. The contiguity of vulvar fascial spaces with other anatomic compartments permits spread of infection from the vulva to the inner thigh, abdominal wall, or ischiorectal fossa. The differential diagnosis of a vulvar abscess includes infectious and non-infectious vulvar lesions. Among the infectious causes, vulvovaginitis presents mostly as erythema and less likely as a suppurative mass. Necrotizing fasciitis though a rare condition may present as an abscess and should be suspected when the lesion is extensive with persistent pain, erythema, and induration. Malignant lesions of the vulva may present as a firm lesion with surrounding erythema. A biopsy should be taken whenever there is a suspicion of malignancy.
In our case the abscess had spread over a wide area. The only history which was elicited was of itching and scratching over the left side of vulva few days prior to onset of symptoms. A close watch was kept for further extension of the abscess and development of necrotising fasciitis. But fortunately even though a large area was involved, necrosis and gangrene did not occur. Probably the parenteral antibiotics received in the private hospital prevented the causative organisms from growing and multiplying (as seen by negative pus culture report). The decision of conventional incision and open drainage by the surgeons was made in view of the large extension of the abscess. In some cases closure by primary suturing may be done under antibiotic cover. She had preterm premature rupture of membranes probably due to some ascending infection that was not detected on cervical swab due to antibiotic use. Fortunately her abdominal wound healed well and she had no spread of sepsis as special care was taken to isolate her abscess site during the cesarean section. A midline vertical incision for cesarean section that was taken avoided the inevitable lateral extension into the infected left lower abdominal tissue planes.
This interesting case highlights the need of a multidisciplinary approach involving the general surgeons and reconstructive plastic surgeons. Timely drainage and breaking of all loculi and regular dressing can bring out a favorable outcome even in a large vulvar abscess.
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Thakare R, Thosar MA, Gupta AS. Vulvar Abscess In A Pregnant Woman. JPGO 2017. Volume 4 No.2. Available from: http://www.jpgo.org/2017/02/vulval-abscess-in-pregnant-woman.html