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Gynecologic rarities: a case of periclitoral abscess and review of the literature

2012; Elsevier BV; Volume: 207; Issue: 5 Linguagem: Inglês

10.1016/j.ajog.2012.08.029

1097-6868

George A. Koussidis,

Genital Health and Disease

Periclitoral abscess is a rare entity, with publications limited to case reports. We present here a case of periclitoral abscess in a 17 year old patient, which was treated with incision and drainage. We also review all the similar cases that have been reported in the English literature until now. Periclitoral abscess is a rare entity, with publications limited to case reports. We present here a case of periclitoral abscess in a 17 year old patient, which was treated with incision and drainage. We also review all the similar cases that have been reported in the English literature until now. Abscess of the periclitoral area is a rare gynecological condition with few cases reported; therefore, correlation with specific causes is difficult. A significant number of cases are patients who had been subjected to genital mutilation procedures of religious motives.1Dave A.J. Sethi A. Morrone A. Female genital mutilation: what every American dermatologist needs to know.Dermatol Clin. 2011; 29: 103-109Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In such cases, periclitoral abscess formation follows the development of postsurgical inclusion cysts, which get infected.2Rouzi A.A. Epidermal clitoral inclusion cysts: not a rare complication of female genital mutilation.Hum Reprod. 2010; 25: 1672-1674Crossref PubMed Scopus (35) Google Scholar, 3Dirie M.A. Lindmark G. A hospital study of the complications of female circumcision.Trop Doct. 1991; 21: 146-148PubMed Google Scholar Conversely, there are periclitoral abscess cases that occur spontaneously without any previous local surgery. Such spontaneous development is difficult to be associated with specific causes because these cases are rare. Therefore, available treatment options are based on personal experience and not on enough available evidence. A 17 year old patient (para 0; gravida 0) was referred, complaining of severe genital pain and swelling of 12 hours' duration. She was afebrile and able to pass urine. Her past medical history was unremarkable. On examination, a prominent lump of 2 cm was noted arising from the prepuce (Figure). The lump was tender and fluctuant, suggestive of fluid collection. A concomitant swelling of the left labia minora was apparent, but the rest of the genital structures appeared normal. The abscess was incised and drained under local anesthesia. Cultures revealed coagulase positive Staphylococcus and Bacteroides species. The patient was discharged within the same day. No recurrence was recorded after 8 months of follow-up. Excluding the reports in which a periclitoral abscess was the result of female clitoral mutilation (complicated circumcision of religious motives), in total 18 reports of spontaneous periclitoral abscesses have been published in the English medical literature, including the presented case (Table). In most of the reported cases, the etiology for the development of such spontaneous abscesses was unclear. A speculative pathogenetic mechanism could be a defect of the squamous stratified epithelium that permits the entrance of pathogens. Indeed, several microorganisms that cause purulent infections have been isolated in some of the published cases: coagulase-positive Staphylococcus, Streptococcus bovis, Diptheriae species, and Bacteroides species.4Sur S. Recurrent periclitoral abscess treated by marsupialization.Am J Obstet Gynecol. 1983; 147: 340PubMed Scopus (12) Google Scholar, 5Kent S.W. Taxiarchis L.N. Recurrent periclitoral abscess.Am J Obstet Gynecol. 1982; 142: 355-356Abstract Full Text PDF PubMed Scopus (10) Google ScholarTABLEReported spontaneous periclitoral abscess casesYearAuthorAge, ySize, cmFeaturesCulturesTreatment of first episode (history data)RecurrenceDefinitive management1957Palmer10Palmer E. Pilonidal cyst of the clitoris.Am J Surg. 1957; 93: 133-136Abstract Full Text PDF PubMed Scopus (22) Google Scholar294Pilonidal a.None reportedSpontaneous drainageOne within 1 yExcision of cyst-track1962Betson et al11Betson Jr, J.R. Chiffelle T.L. George R.P. Pilonidal sinus involving the clitoris A case report.Am J Obstet Gynecol. 1962; 84: 543-545PubMed Scopus (15) Google Scholar29Pilonidal a.None reportedSpontaneous drainageOne within 1 yExcision of cyst-track1972Radman and Bhagavan8Radman H.M. Bhagavan B.S. Pilonidal disease of the female genitals.Am J Obstet Gynecol. 1972; 114: 271-272Abstract Full Text PDF PubMed Scopus (19) Google Scholar223Pilonidal a.None reportedIncisionMultiple for 2 yExcision of cyst-track1975Devroede et al7Devroede G. Schlaeder G. Sanchez G. Haddad H. Crohn's disease of the vulva.Am J Clin Pathol. 1975; 63: 348-358PubMed Google Scholar281Crohn's d.Staphylococcus aureus, Staphylococcus epidermidis, PeptostreptococcusSpontaneous drainageNo (follow-up 5 mo)1980Reeves and Kaufman6Reeves K.O. Kaufman R.H. Vulvar ectopic breast tissue mimicking periclitoral abscess.Am J Obstet Gynecol. 1980; 137: 509-511PubMed Scopus (14) Google Scholar294Breast tissueNone reportedIncisionOne after 8 dExcision of mass1982Kent and Taxiarchis5Kent S.W. Taxiarchis L.N. Recurrent periclitoral abscess.Am J Obstet Gynecol. 1982; 142: 355-356Abstract Full Text PDF PubMed Scopus (10) Google Scholar242NonspecificNone reportedIncisionMultiple for 11 yConservative1982Kent and Taxiarchis5Kent S.W. Taxiarchis L.N. Recurrent periclitoral abscess.Am J Obstet Gynecol. 1982; 142: 355-356Abstract Full Text PDF PubMed Scopus (10) Google Scholar232NonspecificNone reportedSpontaneous drainageMultiple for 6 yMarsupialization1982Kent and Taxiarchis5Kent S.W. Taxiarchis L.N. Recurrent periclitoral abscess.Am J Obstet Gynecol. 1982; 142: 355-356Abstract Full Text PDF PubMed Scopus (10) Google Scholar293NonspecificBacteroides, DiptheroidesSpontaneous drainageOne after 10 yMarsupialization1982Kent and Taxiarchis5Kent S.W. Taxiarchis L.N. Recurrent periclitoral abscess.Am J Obstet Gynecol. 1982; 142: 355-356Abstract Full Text PDF PubMed Scopus (10) Google Scholar31NonspecificCoag-positive StaphylococcusIncisionMultiple for 18 moMarsupialization1983Sur4Sur S. Recurrent periclitoral abscess treated by marsupialization.Am J Obstet Gynecol. 1983; 147: 340PubMed Scopus (12) Google Scholar413NonspecificStreptococcus bovisIncisionOne after 2 moMarsupialization1983Sur4Sur S. Recurrent periclitoral abscess treated by marsupialization.Am J Obstet Gynecol. 1983; 147: 340PubMed Scopus (12) Google Scholar163NonspecificNone identifiedIncisionTwo in 3 moMarsupialization1990Werker and Kon12Werker P.M. Kon M. A pilonidal sinus of the clitoris?.Ann Plast Surg. 1990; 25: 63-64Crossref PubMed Scopus (13) Google Scholar233Pilonidal a.None reportedLocal excisionMultiple in 1 yExcision of cyst-track2003Chinnock14Chinnock B. Periclitoral abscess.Am J Emerg Med. 2003; 21: 86Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar415No biopsyNone reportedConservativeNo (follow-up not reported)2004Lara-Torre et al15Lara-Torre E. Hertweck S.P. Kives S.L. Perlman S. Premenarchal recurrent periclitoral abscess: a case report.J Reprod Med. 2004; 49: 983-985PubMed Google Scholar11No biopsyNone reportedSpontaneous drainageNo (follow-up 6 mo)2007Mendilcioglu16Mendilcioglu I. Recurrent periclitoral abscess: treatment of a rare cause of vulvar pain.Eur J Obstet Gynecol Reprod Biol. 2007; 131: 101-102Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar334No biopsyNone identifiedSpontaneous drainage at age 12One after 21 yMarsupialization2008Baker et al9Baker T. Barclay D. Ballard C. Pilonidal cyst involving the clitoris: a case report.J Low Genit Tract Dis. 2008; 12: 127-129Crossref PubMed Scopus (15) Google Scholar302Pilonidal a.None reportedIncisionMultiple for 2 yExcision of cyst-track2010Maor-Sagie et al13Maor-Sagie E. Arbell D. Prus D. Israel E. Benshushan A. Pilonidal cyst involving the clitoris in an 8-year-old girl—a case report and literature review.J Pediatr Surg. 2010; 45: e27-e29Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar81Pilonidal a.None reportedLocal excisionOne within 3 moExcision of tract2011Current case172No biopsyCoag-positive StaphylococcusIncisionNo (follow-up 8 mo)English-language literature was reviewed using the PubMed service (National Library of Medicine, Bethesda, MD). Publications from Jan. 1, 1950, through April 23, 2012, were searched, using the following terms: “periclitoral abscess,” “clitoral abscess,” “clitoral inflammation,” “periclitoral inflammation,” and “clitoral pilonidal” in various combinations. Publications reporting clitoral abscesses as complications of religious female genital mutilation procedures were excluded.a, abscess; Coag, coagulant; d, disease.Koussidis. Periclitoral abscess. Am J Obstet Gynecol 2012. Open table in a new tab English-language literature was reviewed using the PubMed service (National Library of Medicine, Bethesda, MD). Publications from Jan. 1, 1950, through April 23, 2012, were searched, using the following terms: “periclitoral abscess,” “clitoral abscess,” “clitoral inflammation,” “periclitoral inflammation,” and “clitoral pilonidal” in various combinations. Publications reporting clitoral abscesses as complications of religious female genital mutilation procedures were excluded. a, abscess; Coag, coagulant; d, disease. Koussidis. Periclitoral abscess. Am J Obstet Gynecol 2012. In another case, a periclitoral abscess was formed in the setting of ectopic breast tissue, whereas at least 1 case of periclitoral abscess has been reported in a patient with Crohn's disease.6Reeves K.O. Kaufman R.H. Vulvar ectopic breast tissue mimicking periclitoral abscess.Am J Obstet Gynecol. 1980; 137: 509-511PubMed Scopus (14) Google Scholar, 7Devroede G. Schlaeder G. Sanchez G. Haddad H. Crohn's disease of the vulva.Am J Clin Pathol. 1975; 63: 348-358PubMed Google Scholar Interestingly, in a distinctive group of patients, the development of periclitoral abscess has been shown to arise as a complication of what was proven to be an existing pilonidal sinus tract of the clitoris.8Radman H.M. Bhagavan B.S. Pilonidal disease of the female genitals.Am J Obstet Gynecol. 1972; 114: 271-272Abstract Full Text PDF PubMed Scopus (19) Google Scholar, 9Baker T. Barclay D. Ballard C. Pilonidal cyst involving the clitoris: a case report.J Low Genit Tract Dis. 2008; 12: 127-129Crossref PubMed Scopus (15) Google Scholar, 10Palmer E. Pilonidal cyst of the clitoris.Am J Surg. 1957; 93: 133-136Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 11Betson Jr, J.R. Chiffelle T.L. George R.P. Pilonidal sinus involving the clitoris A case report.Am J Obstet Gynecol. 1962; 84: 543-545PubMed Scopus (15) Google Scholar, 12Werker P.M. Kon M. A pilonidal sinus of the clitoris?.Ann Plast Surg. 1990; 25: 63-64Crossref PubMed Scopus (13) Google Scholar, 13Maor-Sagie E. Arbell D. Prus D. Israel E. Benshushan A. Pilonidal cyst involving the clitoris in an 8-year-old girl—a case report and literature review.J Pediatr Surg. 2010; 45: e27-e29Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar In fact, this etiology was so abundant between the reported cases that it should always be taken into consideration when dealing with a periclitoral abscess case. All of these patients presented multiple recurrences until definite treatment, which was the complete excision of the pilonidal sinus tract. There is no established optimal management for periclitoral abscesses. In all of the reports the choice of management was subjective and based on personal experience. From the 18 reported cases, 8 were treated expectantly during the first episode, until spontaneous drainage or resolution, 8 with simple incision and 2 with local excision (Table). Almost all of the cases presented recurrences in the following months or years after the first episode, which were irrespective to the initial method of treatment. These findings do not lead to any conclusion that favors expectant or surgical management as a proper treatment of the initial episode. As for recurrent episodes, it seems to be sensible to offer either marsupialization or excision of the abscess cavity as treatment options. In conclusion, spontaneous periclitoral abscess is a rare entity with no established management options. Expectant management does not pose the risk of potential damage to the clitoris from the incision. Thus, expectant management could potentially be reserved for those patients in whom the anatomic boundaries of the clitoris in relation to the prepuce are not clearly demarcated. When abscesses are large or when a somewhat quicker resolution of symptoms is needed, a surgical approach can be reasonably followed, during the first episode. It is, however, important that the surgeon identifies any cord-like structure pointing toward the mons pubis, indicating a pilonidal abscess, which would require excision of the tract. Further studies are needed to refine the different management options and clinical features of this rare disorder.