1. Subjective
Patients chief complaint, reason for visit
Ms. Richards arrived complaining that she was experiencing severe anal pain, so much so that using a tissue was also proving impossible. She claimed the pain began a couple of days earlier and has aggravated considerably since.
History of Present Illness
Ms. Richards arrived complaining of anal pain which commenced a couple of days earlier and has aggravated since. With regard to her intimate relationships, Ms. Richards states that though she has a boyfriend, their relationship isnt serious as the two are also seeing other people. According to internal assessment reports, patient has normal hair distribution, an intact perineum, and intact urethral meatus without any discharge or inflammation. However, patient experiences unbearable pain on vaginal opening palpation, redness, and edema. Further, a mass has been identified on the right, with spontaneous, dark-yellow, smelly secretion with palpation over the Bartholin’s glands.
Physical examination reports reveal normal vital signs, cardiovascular, respiration and acute abdomen limits. A non-tender, soft mass, mobile relative to underlying muscle and bone, was palpated. Soft tissue was found to be swollen and highly prominent at the posterior. No tenderness was observed to thigh palpation, nor was any evidence discovered of warmth or erythema across the region. Passive and active range of knees and hips bilateral motion was painless and full. Lower bilateral extremities had typical tone and strength. A neurologic examination of patients lower extremity depicted normal results. Musculoskeletal examination results and gait were also found to be normal (King, Friedman, Iwenofu, & Ogilvie, 2008).
Precipitating/alleviating factors
Patient claims to enjoy an open romantic relationship and active sex life. She often consumes birth control medication and has even taken painkillers for alleviating her anal pain.
Past Medical History
Patient reports never having met with an accident, nor has she suffered any serious ailment, admission to a hospital, or surgery. Patient is somewhat overweight, with a small quantity of thigh fat. She states that in spite of exercising and eating healthy, her thighs have remained the same.
Family History
Patients dad was diabetic while her grandma was found to be suffering from cancer somewhere in her fifties.
Social History
Patient enjoys a healthy relationship with family members. She is employed as a primary school teacher, which is why she can easily afford her apartments rent. She enjoys an open romantic relationship and active sex life.
Review of Systems
System review proved non-contributory, with physical examination results being typical. Peripheral blood count, urinalysis and serum chemistry at the time of hospitalization were normal.
2. Objective
Diagnostic Study
Bartholin’s gland infection
Situated in a symmetrical arrangement at the vaginal openings posterior are a couple of pea-sized Bartholins glands, which have a key role to play in womens reproductive system. Their function is secreting mucus and lubricating the vagina. Cysts commonly form within these glands, on account of accumulation of mucus within the gland ducts. Monitoring these cysts is vital owing to the fact that they can develop as carcinomas. Larger abscesses and cysts develop within the lower vestibule area, presenting, usually, with edema and erythema. One efficient means of differentiating Bartholin’s glands cysts from differential diagnoses is through biopsy. Smaller, asymptomatic cysts can be left as they are but larger ones call for medical attention. There are a number of treatment alternatives available, such as CO2 laser and marsupialization. Treatment and recuperation hinge on therapeutic course and infection severity (Lee, et al., 2015).
Assessment
Pathophysiology
Cysts often emerge as one Bartholins gland complication, impacting the ductal area on account of outlet blockage (Antvorskov et al, 2014). Obstruction of the gland duct opening results in mucus accumulation, in turn resulting in cystic duct dilation and eventual cyst formation. Cyst infection then tends to occur in gland abscesses. Duct cysts arent a precondition for abscess development. Abscesses are nearly thrice more common as compared to duct cysts and Bartholin’s gland abscess cultures frequently reveal polymicrobial infection (Lee, et al., 2015).
Bartholins gland lesions may develop as carcinomas, a seldom-occurring gynecological tumor form accounting for between 2 and 7 percent of carcinomas of the vulva. Such vulvar growths are monitored carefully in the postmenopausal population, which is at greater risk of Bartholin’s malignancy development (Lee, et al., 2015). Bartholins gland cancer is diagnosed at a median 57 years of age, with carcinoma rates being highest in females over 60 years of age. Squamous cell and adeno carcinoma, which are the mostly commonly occurring types, make up 80 to 90 percent of all primary cases, while the rest are largely transitional, undifferentiated or adenoid-cystic carcinomas. HPV or human papillomavirus represents the sole type associated with lesions of the squamous cells. Benign tumors occur more infrequently as compared to carcinomas. Bartholin’s glands abscesses are largely bacterial culture-+ve (Escherichia coli is a widely-identified pathogen). While deciding on antibacterial therapeutic alternatives, correlating microbiological findings to anti-biograms is pivotal (KEssous et al, 2013).
Differential Diagnosis
Genital leiomyomas
Genital leiomyoma is an infrequently occurring tumor potentially misdiagnosed as a Bartholins cyst. These develop most frequently within the uterus as well as, to a certain extent, within the cervix, the round utero-sacral ligament, inguinal canal and ovary. Seldom do they develop in the vagina, but when they do, they are largely diagnosed among women aged between 35 and 50 years; further, Caucasian females display highest incidence (Chakrabarti, De, & Pati, 2011). Leiomyoma normally manifests in the form of a well-circumscribed, single mass that arises from midline anterior walls; it develops less commonly at the lateral and posterior walls. They can be asymptomatic; however, based on occurrence location, they may result in numerous symptoms such as pain in the lower abdomen, lower back pain, dyspareunia, vaginal bleeding, dysuria, frequent micturation, and other urinary obstruction features. The tumors may be pedunculated or intramural, cystic or solid (Chakrabarti, De, & Pati, 2011).
Leiomyomas Fibroma
Uterine fibroids or leiomyomas represent non-cancerous tumors that arise within uterine wall smooth muscles. They occur very commonly in the reproductive age population, with roughly 60-80 percent of females likely to be impacted at age fifty. These tumors etiology is yet to be properly understood; however, their origin is monoclonal (they originate out of the same precursor cell). Their mechanism of development has yet to be deduced; however, several factors contribute to their development, including sex steroids which are most commonly focused on by researches on the subject (Mended et. al, 2015). Disease heterogeneity as regards leiomyoma size, symptomatology, location, and growth trajectory constitutes one solid barrier to innovation. Symptomatic leiomyoma varies from a small, non-palpable size to those sufficiently large to distort the abdominal contour of the individual to mimic pregnancy (Laughlin & Stewart, 2012).
Hidradenoma
Hidradenoma papilliferum constitutes another non-malignant epidermal appendage tumor developing in apocrine sweat glands abundantly found in the anogenital skin region. The reason for its development here has been assumed to be its histopathological likeness to intraductal breast papilloma and palpable estrogen receptors. Most lesions are discovered within adult womens perianal or vulvar regions. However, in spite of previous clues, this condition may develop even in extragenital regions and among men (Al-Faky et al, 2009). Another anogenital cystic lesion is Bartholin’s abscess, caused due to total or partial ductal obstruction with development of abscess after infection. Concomitant Hidradenoma papilliferum and Bartholin’s abscess is a unique condition (Al-Faky et al, 2009).
3. Plan
Diagnostics
Asymptomatic cysts in the Bartholin’s glands may be left as they are, without any negative repercussions. Incision, infected region drainage and suture closure is a swift and efficient means of offering relief; but the abscess or cyst may recur through this technique. Sitz baths represent the recommended treatment for spontaneously rupturing abscesses (King, Friedman, Iwenofu, & Ogilvie, 2008).
Radiology: Computed tomography and magnetic resonance imaging (MRI) may help examine large cysts in the Bartholin’s duct, besides physical examination. Further, MRI scans may facilitate examination of asymptomatic cysts. High definition ultrasounds may help reveal Bartholin’s cyst presence as well (Lee, et al., 2015).
Marsupialization: This represent an alternative option for treating Bartholin’s gland cysts, enabling less invasive cyst drainage. The cyst is clasped using small hemostats and the infected is drained via a vertical incision (roughly 1.5 to 3 cm in length). The region may be moistened using saline solution, and cyst wall eversion subsequently performed using absorbable suture. Marsupialization is not recommended for abscesses owing to potential associated complications like hematoma, infection and dyspareunia (Omole et al, 2003).`
Therapeutic Plan
As widely-adopted treatment techniques present the disadvantages of scarring, recurrence, hemorrhage and persistent drainage, CO2 laser is an advantageous way to avoid these side-effects. CO2 lasers are used to make a cyst incision, with the wall internally vaporized. According to reports, this method leaves no scars and shows minimal recurrence rates (Lee, et al., 2015).
Other Bartholin’s glands abscess and cyst treatment techniques include needle aspiration without or with alcohol sclerotherapy, gland excision and silver nitrate gland ablation (Wechter et al, 2009). Antibiotics might not be needed in case of healthy patients having uncomplicated abscesses. The option ought only to be used for patients with high complication risks including recurrence, MRSA risk, pregnancy, widespread surrounding gonorrhea, chlamydia infection, and cellulitis and immunosuppression. Common antibiotic prescribed are Ceftriaxone, Azithromycin, Ciprofloxacin, and Doxycycline. Abscesses are also treated using lidocaine, bupivacaine, and other local or topical anesthetics (Lee, et al., 2015).
Bartholin’s carcinoma treatments include surgical methods, radiotherapy or vulvectomy. Hyperbaric oxygen treatment and subsequent radical vulvectomy fosters wound healing. A seldom occurring Bartholin’s cancer malignancy is primary adenoid cystic carcinoma. Patients may undergo hemivulvectomy or adjuvant external beam radiation. Lymphadenectomy may be used in case of initial stage I Bartholin’s carcinoma (Lee, et al., 2015).
Education
Patient and family education will commence soon after diagnosis confirmation on the basis of test outcomes. Education elements will include risk factors, diet and exercise, lifestyle modifications, routine check-ups/follow-ups, smoking cessation, and treatment adherence. Interdisciplinary patient care team members must reiterate the significance of patient and family education.
Community Resources
Community resources include internet forums for discussion, where members can support and advise others. Further, weekly support groups aid patients during treatment and recovery.
Referral
Emergency marsupialization was advised in case of Ms. Richards, with her informed consent garnered. The following pre-surgical antibiotics were administered: ciprofloxacin (500 mg) administered twice a day, orally, for five days; metronidazole (400?mg) administered three times a day, orally, for a week; and doxycycline (100?mg) administered orally for a week (Lilungulu et. al, 2017).
Follow-up
In post-surgical care, the patient continued with the aforementioned antibiotics, in addition to the analgesic, paracetamol (1?g) administered thrice a day, orally, for three days. Patient was de-hospitalized on day 3 and referred to a reproductive health center to receive counseling on prevention and treatment of sexually transmitted infections (Lilungulu et. al, 2017).
Bibliography
Al-Faky, et. al, (2009). Periocular hidradenoma papilliferum. Saudi J Ophthalmol. 23(3-4): 211213.
Antvorskov JC, Josefsen K, Engkilde K, Funda DP, Buschard K. (2014). Dietary gluten and the development of type 1 diabetes. Diabetologia. 75:17701780
Chakrabarti, et al. (2011). Vaginal leiomyoma. Journal of Mid-life Health. 2:42-43.
Kessous R, Aricha-Tamir B, Sheizaf B, Steiner N, Moran-Gilad J, Weintraub AY (2013). Clinical and microbiological characteristics of Bartholin gland abscesses. Obstet Gynecol; 122:794799
King, J., Friedman, J., Iwenofu, H., & Ogilvie, C. (2008). Buttock Mass in a 46-year-old Woman. Clin Orthop Relat Res., 20232028.
Lee, et. al, (2015). Clinical pathology of bartholin’s glands: a review of the literature. Curr Urol. 8(1):22-5.
Lilungulu et. al., (2017). Recurrent huge left bartholin’s gland abscess for one year in a teenager. Case Rep Infect Dis.
Omole F, Simmons BJ, Hacker Y. (2003). Management of Bartholin’s duct cyst and gland abscess. Am Fam Physician. 68:135140.
Wechter ME, Wu JM, Marzano D, Haefner H. (2009). Management of Bartholin duct cysts and abscesses: a systematic review. Obstet Gynecol Surv. 64:395404.
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