Greater Vestibular (Bartholin) Gland Abscess Case File

Greater Vestibular (Bartholin) Gland Abscess Case File

Eugene C. Toy, MD, Lawrence M. Ross, MD, PhD, Han Zhang, MD, Cristo Papasakelariou, MD, FACOG

CASE 27

A 27-year-old female notes a tender lump in her groin area that appeared approximately 3 weeks ago. She relates that she had a similar mass about 1 year ago that required minor surgery. On physical examination, she is afebrile, and inspection of the perineum shows a 3 × 2-cm fluctuant mass at the five-o’clock position of the vestibule. It is mildly tender, red, and slightly warm to the touch.

⯈ What is the most likely diagnosis?

⯈ What structures are causing the groin enlargement?

ANSWER TO CASE 27:

Greater Vestibular (Bartholin) Gland Abscess

Summary: A 27-year-old female notes a tender lump in the groin that appeared 3 weeks ago. She had surgery for a similar mass a year ago. The patient is afebrile and has a 3 × 2-cm fluctuant, inflamed mass at the five-o’clock position of the vestibule.

• Most likely diagnosis: Greater vestibular (Bartholin) gland abscess

• Cause of groin lump: Inguinal lymph nodes

CLINICAL CORRELATION

This young woman notes the appearance of an inflamed, perineal, or vulvar mass in the posterolateral region of the vestibule. She apparently had a similar lesion 1 year previously. These findings are very consistent with a greater vestibular (Bartholin) gland infection. The greater vestibular glands are located at the five- and seveno’clock positions of the vulva. If the ducts of the glands become obstructed, the glands may enlarge and become infected, usually with multiple organisms other than those responsible for sexually transmitted diseases. Lymphatic drainage of the vulva is first to the inguinal lymph nodes. Treatment for this patient is to create a fistulous tract to decrease the incidence of recurrence; the two most common methods are incision and drainage with a catheter left in place for several weeks and marsupialization of the cyst wall, which is suturing the inner lining of the cyst wall to the epithelium around the periphery of the cyst. Biopsy is typically not required in a young patient, but for vulvar masses or abnormalities in women older than 40 years it is required to rule out malignancy.

APPROACH TO:

The Vulva

OBJECTIVES

1. Be able to define the boundaries of the perineum

2. Be able to describe the urogenital triangle

3. Be able to describe the lymphatic drainage of the perineum

DEFINITIONS

VULVA: The region of the external genitalia of the female

GREATER VESTIBULAR GLANDS: Bartholin glands; two small reddish bodies on the posterolateral aspects of the vestibule

MARSUPIALIZATION: Surgical procedure in which the inner lining of the cyst wall is sutured to the epithelium around the periphery of the cyst to promote cyst drainage

DISCUSSION

The perineum is defined as the region of the trunk, between the thighs and buttocks, inferior to the pelvic diaphragm. It is bounded bilaterally by the pubic symphysis (anterior), ischiopubic ramus (anterolateral), ischial tuberosity (lateral), sacrotuberous ligament (posterolateral), and the coccyx (posterior). A line between the ischial tuberosities divides the perineum into anterior and posterior urogenital and anal triangles, respectively. Deep to the skin is the fatty layer of superficial fascia, a continuation of a similar layer in the abdomen (Camper fascia). In the abdomen, deep to the fatty layer is the membranous layer of superficial fascia (Scarpa fascia) that continues into the perineum, where it is called Colles fascia. In the perineum, Colles fascia is attached laterally to the fascia lata of the thigh and to the posterior border of the perineal membrane and the perineal body. The perineal membrane is a thin but strong fascial sheet attached to the ischiopubic rami, thus stretching across the urogenital triangle. The potential space between the deep layer of the superficial (Colles) fascia and the perineal membrane is the superficial perineal pouch (space). Attached to the superior surface of the perineal membrane are the deep transverse perineal and sphincter urethrae muscles within the deep perineal pouch (space). The perineal body attaches to the posterior edge of the membrane at its midpoint (Figures 27-1 and 27-2).

Superficial to the perineal membrane, the pudendum or vulva (external genitalia) includes the mons pubis and labia majora, labia minora, vaginal vestibule, bulbs of the vestibule, greater vestibular (Bartholin) glands, clitoris, and the associated ischiocavernosus and bulbospongiosus muscles. The mons pubis is a rounded, hair-covered elevation anterior to the pubic symphysis formed by a mass of the fatty layer of the superficial fascia. Fat-filled posterior extensions of the mons form the hair-covered labia majora, which are united by anterior and posterior commissures.

Figure 27-1. External female genitalia. (Reproduced, with permission, from Decherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: McGraw-Hill, 2003:17.)

Figure 27-2. Interior view of female pelvic musculature. (Reproduced, with permission, from Decherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: McGraw-Hill, 2003:22.)

The space between the two labia is the pudendal cleft. Medial to each labia majora are the thin, fat-free, hairless labia minora that are filled with erectile tissue and surround the vestibule of the vagina, which contains the urethral and vaginal orifices. The labia minora are united posteriorly by the frenulum of the labia minora or fourchette. Anteriorly, the two labia minora are united by extensions that pass anterior and posterior to the glans of the clitoris as the prepuce and frenulum of the clitoris, respectively. The clitoris is composed of paired cylinders of erectile tissue or corpora cavernosa attached to the ischiopubic rami as the two crura and are surrounded by the ischiocavernosus muscles. The corpora cavernosa converge toward the pubic symphysis to form the body, which is sharply flexed inferiorly and terminates as the glans anterior to the urethral orifice. Superior (deep) to the labia majora and minora, at the margins of the vestibule, are the paired bulbs of the vestibule. At the posterior ends of the bulbs and partially embedded in them are the paired greater vestibular (Bartholin) glands. The bulbs and glands are covered by the bulbospongiosus muscles. A superficial transverse perineal muscle lies along the posterior edge of the perineal membrane and attaches laterally to the ischial tuberosity and medially to the perineal body. The components of the clitoris, bulb of the vestibule, greater vestibular gland, and the bulbospongiosus and ischiocavernosus muscles are encased in the deep perineal or investing (Gallaudet) fascia. The bulbospongiosus, superficial, and deep transverse perineal, and external anal sphincter muscles attach to the perineal body.

The lymphatic drainage of the perineum is primarily to the superficial inguinal lymph nodes, which lie inferior and parallel to the inguinal ligament. Efferent vessels from this group drain lymph to the external iliac nodes, but some lymph does drain to the deep inguinal nodes, which then drain to the external iliac nodes. Small amounts of lymph from deep perineal structures drain to the internal iliac nodes.

COMPREHENSION QUESTIONS

27.1 A 34-year-old woman who has diabetes develops a boil on the right labia majora. Which of the following lymph nodes is most likely to be enlarged in response to the infection?

A. Internal iliac

B. External iliac

C. Superficial inguinal

D. Obturator

27.2 Which of the following structures divides the perineum into the genitourinary and anal triangles?

A. Levator ani muscles

B. Superficial transverse perineal muscle

C. Line from the ischial tuberosities

D. Anal verge

27.3 A 24-year-old woman is undergoing a vaginal delivery. A midline episiotomy is performed that incises into the perineal body. Which of the following muscles is most likely to be cut during this process?

A. Superficial transverse perineal muscle

B. Levator ani muscle

C. Puborectalis muscle

D. Pubococcygeus muscle

ANSWERS

27.1 C. The primary drainage of the vulva is the superficial inguinal nodes.

27.2 C. A line between the two ischial tuberosities divides the perineum into the genitourinary triangle (anteriorly) and the anal triangle (posteriorly).

27.3 A. The muscles that attach to the perineal body are the bulbospongiosus, superficial, and deep transverse perineal muscles, and the external anal sphincter.

ANATOMY PEARL

⯈ The clitoral structures, vestibular bulb, greater vestibular gland, and associated muscles are located in the superficial perineal pouch (space).

⯈ The bulbospongiosus, ischiocavernosus, superficial, and deep transverse perineal, and sphincter urethral muscles are innervated by the pudendal nerve.

⯈ The primary lymphatic drainage of the perineum is to the superficial inguinal lymph nodes.

References

Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy, 2nd ed. New York, NY: Thieme Medical Publishers; 2012:248, 267. 

Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy, 7th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2014:402−406, 428−431, 433. 

Netter FH. Atlas of Human Anatomy, 6th ed. Philadelphia, PA: Saunders; 2014: plates 354, 356−357, 382.

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