American Journal of Clinical Microbiology and Antimicrobials Research Article

Published: 01 May, 2018

Complicated Major Labia Abscess - Clinical Manifestation

and Microbiology of Hospitalized Women
Anat Shmueli, Yoav Peled*, Anat From, Ram Eitan, Arnon Wiznitzer and Haim Krissi
Department of Obstetrics and Gynecology, Tel Aviv University, Israel

Abstract
Background: Women hospitalized with complicated Non-Bartholin major labia abscesses an
uncommon insufficient investigated entity. The purpose of this study was to explore these patients
characteristics, there clinical manifestation, mode of treatment and microbiology.
Methods: Hospitalized women with a diagnosis of major labia abscess were followed at the
gynecological division of a university-affiliated tertiary medical center during January 2004 to
December 2013. Decision for hospitalization was based on clinical symptoms such as severe
pain, fever, swelling, redness and cellulitis, or no response to oral antibiotic treatment. Data on
demographic parameters, age, clinical manifestations, diagnosis, mode of treatment, pus culture,
blood test results, duration of stay and discharge were retrieved from the departmental computerized
health records.
Results: Of 294 women diagnosed and hospitalized for vulvar abscess during the study period, only
27 (9.2%) were diagnosed with major labia abscess and comprised the study group. Mean age was
35.2 ± 13.2 years (range 15-65 years). For all women, this was the first episode of labial abscess.
Severe local pain was the main complaint, recorded for 17 (62.9%). Systemic fever and leukocytosis
were recorded for only 8 (29.6%) and 10 (37.0%) women.
Incision and drainage of the abscess was successful in all cases. There were no cases of recurrent
OPEN ACCESS labial abscesses in our records. Only 33.3% of cultures were positive for bacteria. The most prevalent
species were Streptococcus in 88.9%, Escherichia coli in 22.2% and Staphylococcus in 11.1%.
*Correspondence:
Yoav Peled, Department of Obstetrics
Conclusions: Hospitalization for major labia abscess is uncommon. Incision and drainage with
systemic antibiotics is the appropriate treatment.
and Gynecology, Helen Schneider
Hospital for Women, Rabin Medical Keywords: Major Labia; Vulvar Abscess; Non-Bartholin Abscess
Center – Beilinson Hospital,
PetachTikva 4941492, Israel, Tel: Introduction
00972-3-6194876; Fax: 00972-3-
Vulvar abscess is a common gynecologic problem rarely results in severe illness. The skin and
9377585;
hair follicles of the labial surface are subject to infections common to these structures in other
E-mail: [email protected]
parts of the body. These include folliculitis, skin abscesses, furuncles, and carbuncles. The abscesses
Received Date: 14 Mar 2018
typically originate as simple infections that develop in the labial skin or subcutaneous tissues. Spread
Accepted Date: 24 Apr 2018
of infection and abscess formation in the labial area is facilitated by the loose areolar tissue in the
Published Date: 01 May 2018
subcutaneous layers and the contiguity of the vulvar fascial planes with the groin and anterior
Citation: abdominal wall [1,2]. Labial abscesses have been reported to be mixed polymicrobial infections,
Shmueli A, Peled Y, From A, Eitan R, consisting primarily of Methicillin-Resistant Staphylococcus Aureus (MRSA), enteric gram-
Wiznitzer A, Krissi H. Complicated negative aerobes and female lower genital tract anaerobes [3-5].
Major Labia Abscess - Clinical
The incidence of Non-Bartholin major labia abscess is unknown. Risk factors include obesity,
Manifestation and Microbiology of
poor hygiene, shaving or waxing of pubic hair (e.g., labial trauma), immunocompromised women
Hospitalized Women. Am J Clin
(e.g., diabetes, acquired immunodeficiency syndrome) and pregnancy. However, many women with
Microbiol Antimicrob. 2018; 1(4): 1016.
labial abscesses have no apparent risk factors [1,2].
Copyright © 2018 Yoav Peled. This is
an open access article distributed under Treatment depends upon the lesion size and the patient's risk for failure of therapy or systemic
the Creative Commons Attribution infection. Incision and drainage of a labial abscess is typically managed in the outpatient setting [2].
License, which permits unrestricted Rarely, a labial abscess requires inpatient incision and drainage under regional or general anesthesia.
use, distribution, and reproduction in Indications for such are large size, intractable pain, suspicion that the abscess may extend to another
any medium, provided the original work anatomic compartment (e.g., thigh, anterior abdominal wall), immunocompromised, or post-
is properly cited. drainage complications.

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Yoav Peled, et al., American Journal of Clinical Microbiology and Antimicrobials

The purpose of this study was to explore the patient characteristics, All women were treated with incision and drainage under general
clinical manifestation, and mode of treatment of women hospitalized anesthesia after receiving at least one dose of intravenous antibiotics
with Non-Bartholin major labia abscess. to prevent bacterial spread and systemic inflammatory response.
The first line antibiotic was Amoxicillin/clavulanic acid 1gram, three
Materials and Methods times a day. In cases of known sensitivity or inappropriate clinical
Study population response, the antibiotic treatment was adjusted after consultation
We searched computerized medical records for all women with a specialist in infectious diseases. During surgery, samples were
hospitalized with a diagnosis of labial abscess at the gynecological sent for bacteriological evaluation.
division of a university-affiliated tertiary medical center during Bacteriology
January 2004 to December 2013. Only 9 (33.3%) cultures stained positive for bacteria. The most
The decision for hospitalization and surgical intervention was prevalent species was Streptococcus in 8/9 (88.9%), Escherichia coli
based on clinical symptoms and signs including severe pain, fever, in 2/9 (22.2%) and Staphylococcus in 3.7%. Other species were rare,
swelling, redness and local cellulitis or no response to oral antibiotic and polymicrobial infections were seen in only 1/9 (11.1%) of cases.
treatment. Outcome
Complicated major labia abscesses defined by the need for Incision and drainage of the abscess was successful in all cases.
hospitalization in contrast with labial infections resolved with oral There were no cases of recurrent labial abscesses.
antibiotic and out-patients clinic drainage.
Discussion
The study was approved by the local Institutional Review Board.
We described the clinical manifestations, bacterial
Data collection characterization and mode of treatment for women hospitalized with
Data on demographic parameters, age, clinical manifestations, complicated, non-Bartholin, major labia abscesses. The majority of
major labia abscesses represent anterior extensions of Bartholin
diagnosis, mode of treatment, pus culture, blood test results,
cysts or abscesses [6] whereas other labial abscesses originate from
duration of stay and discharge were retrieved from the departmental
infected sebaceous cysts and folliculitis [7]. Indeed, in this study, only
computerized health records.
27 women were hospitalized with non-Bartholin, major labia abscess
Statistical analysis compared to 267 women hospitalized with Bartholin abscess. The
Statistical analysis was performed with the SPSS software, version different origins of abscesses may explain why Bartholin’s abscesses
20.0 (Chicago, IL). Data were analyzed using descriptive statistics. tend to recur [8], while labial abscesses do not. Thus, a recurrent case
Statistical significance was calculated using the chi-squared test for of labial abscess should be referred to as a new primary abscess, rather
categorical variables and the Student’s t test for continuous variables. than recurrence. In fact, in our entire study group, we had no case of
A multivariate logistic regression model was constructed to identify recurrent labial abscess.
independent factors associated with labial abscess. A p value of less Local pain was the main manifestation of labial abscess, with and
than 0.05 was considered statistically significant. without fever or leukocytosis. Less often recorded were erythema
Results and/or swelling. Leukocytosis was recorded for 37%. These findings
are not surprising, considering that infected sebaceous cysts,
General demographic characteristics especially those arising from Methicillin-Resistant Staphylococcus
Of 294 women diagnosed and hospitalized for vulvar abscess aureus (MRSA) bacteria, tend to manifest as tender, red abscesses [3].
(Bartholin and Non-Bartholin) during January 2004 to December This supports the assumption that labial abscesses arise from infected
2013. Only 27 (9.2%) diagnosed with Non-Bartholin major labia sebaceous cysts of the major labia [6] and may explain the efficacy of
abscess. Reasons for hospitalization were no-response to oral systemic antibiotic treatment and drainage in eliminating the source
antibiotic treatment, severe pain, systemic fever, and the presence of of the abscess. In contrast, for Bartholin duct abscess the main goal of
cellulitis. treatment is creation of re-canalization of the duct [9].In the present
study, we found that incision and drainage, including perioperative
Mean age at diagnosis was 35.2 ± 13.2 years (range 15-65 years). antibiotic treatment was successful in all cases, without recurrence.
Mean number of children was 1.9 ± 2.3. In all women, this was the
first episode of labial abscess. Mean hospitalization time was 1.3 ± In other studies MRSA bacteria was reported as the most common
0.9 days. The vast majority of women (92.6%) did not use the oral organism isolated from labial abscesses. An antibiotic regimen with
contraceptive pill and none used an intrauterine device. sensitivity to MRSA bacteria, such as trimethoprim-sulfamethoxazole,
is recommended in such cases [1,2].Yet, in our population, the most
Clinical characteristics and management common bacteria were Streptococcus species. This difference may be
The most common clinical manifestation was severe local pain due to the anatomical location of these abscesses, and its proximity
reported in 17 women (62.9%). Ten (37.0%) reported local pain and to the vagina, where normal flora contains Streptococcal bacteria.
swelling. Erythema was noted in 5 women (18.5%). On examination, In contrast, the most prevalent bacteria in folliculitis (as well as in
local cellulitis was noted in all women while fever was recorded for 8 Bartholin’s abscess) are Staphylococcus Aureus [6,10].
(29.6%) and leukocytosis in 10 (37.0%). According to the most recent recommendations of the Infectious
Twenty-two women (81.5%) received antibiotic treatment before Disease Society of America, issued in 2014, treatment of inflamed
hospitalization without clinical improvement. For 5 women (18.5%), epidermoid cysts, carbuncles, abscesses, and large furuncles should be
antibiotic treatment was administered in the hospital. by incision and drainage [11]. The decision to administer antibiotics

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Yoav Peled, et al., American Journal of Clinical Microbiology and Antimicrobials

directed against Staphylococcus aureus, as an adjunct to incision and References

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intellectual content: Prof. Arnon Wiznitzer, Prof. Yoav Peled, Prof.
Haim Krissi, Dr. Anat Shmueli.

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