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 isn’t 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 patient’s 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
Patient’s 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 apartment’s 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 opening’s posterior are a couple of pea-sized “Bartholin’s glands”, which have a key role to play in women’s reproductive system. Their function is secreting mucus and lubricating the vagina.
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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 Bartholin’s 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 aren’t 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).
Bartholin’s 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). Bartholin’s 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 Bartholin’s 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….....
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