Images in Women's Health

Recurrent Clitoral Pain and Drainage

Jennifer A. Williams, MD; Hope K. Haefner, MD

CASE HISTORY

A 23-year-old, sexually active, nulligravid woman presented with recurrent periclitoral pain. At initial evaluation, she was noted to have a small area of erythema on the right prepuce; this was treated with an oral cephalosporin and warm soaks. The discomfort resolved, but the patient returned with pain and drainage shortly thereafter. A fluctuant area was incised and drained in the physicianÕs office. The pain and erythema improved again subsequently, but the patient continued to experience pinpoint drainage.

The patientÕs medical history was unremarkable, and past cultures revealed only nonspecific genital flora. Examination in the physicianÕs office revealed a unilateral 2.5- x 1.5-cm fluctuant mass on the prepuce that was somewhat tender and draining purulent material (Figures 1, 2). Possible etiologies included foreign body, infection, vulvar Crohn disease, and endometriosis.

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FIGURE 1. The right prepuce is indurated. Courtesy of Jennifer A. Williams, MD and Hope K. Haefner, MD.

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FIGURE 2. Purulent drainage is noted from the right superior prepuce. Courtesy of Jennifer A. Williams, MD and Hope K. Haefner, MD.

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DIAGNOSIS

Due to the recurrent nature of this abscess, the patient underwent surgery. Intraoperatively, the site of drainage was explored with a lacrimal-duct probe. The patient was found to have a periclitoral abscess secondary to a foreign body. Figure 3 illustrates the findings at a depth of several millimeters. After identifying hair entrapment in an epithelialized (pilonidal) cyst, complete excision of the cyst cavity was performed. The patient has experienced no recurrence since surgery.

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FIGURE 3. Several pieces of hair entrapped within the cavity are noted. Courtesy of Jennifer A. Williams, MD, and Hope K. Haefner, MD.

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DISCUSSION

Periclitoral abscesses have been reported in the literature.1,2 This case demonstrates a chronic inflammatory process resulting from an accumulation of hair shafts that had been driven into the prepuce, consistent with a pilonidal cyst. A pilo (hair) nidal (nest) cyst is an enclosed sinus tract lined by squamous epithelium and containing hair shafts. It is a chronic inflammatory condition, and may occur in any region that is in direct contact with hair. Most commonly, pilonidal cysts are found in the sacrococcygeal area and the axilla, although they have also been reported interdigitally in barbers and animal groomers, as well as in amputation stumps.3 One unusual case has been reported describing a pilonidal cyst presenting with erectile dysfunction and intermittent inflammation of the glans penis. It was suggested that small pieces of hair had accumulated in the cleft of the coronal sulcus, and were subsequently driven into the shaft and prepuce by movement between the two surfaces.4 The case reported here is anatomically analogous to this male case, in that small pieces of hair probably accumulated near her prepuce and were ultimately driven into the epidermis due to movement. Once driven into the epidermis, epithelialization could occur in the tract surrounding the hair, leading to chronic pain and discharge.

Other diagnoses to consider included a gonococcal infection of the vulva. However, vulvar infections tend to be polymicrobial rather than one infectious agent. Gonococcal infections often present with asymptomatic cervicitis or urethritis, as well as anal and oropharyngeal infections and ascending infections (eg, salpingitis). Gonococcal vulvar involvement (for example in a BartholinÕs gland abscess) is extremely rare.

Vulvar Crohn disease was considered in the differential diagnosis, but while pain and sinus tracts also occur with this condition, there is typically more induration and erythema. In some cases, there may be a Òknife-cutÓ appearance or a well-formed fistulous tract. Additionally, most patients with vulvar Crohn disease have a history of bowel involvement.

Vulvar endometriosis has been reported on the vulva4; however, these lesions tend to have a dark-blue (or occasionally flesh-colored) appearance. Additionally, the pain tends to be cyclical, with bloody, not purulent, drainage.5,6

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CONCLUSION

The recurrent nature of this patientÕs symptoms, despite antibiotic and analgesic therapy, suggested a cause beyond simple infection. Surgery was required both to establish the diagnosis and to provide definitive treatment.

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Jennifer A. Williams, MD, is clinical assistant professor; and Hope K. Haefner, MD, is associate professor. Both are in the Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor.

References

1. Chinnock B. Periclitoral abscess. Am J Emerg Med. 2003;21(1):86
2. Lara-Torre E, Hertweck SP, Kives SL, Perlman S. Premenarchal recurrent periclitoral abscess: a case report. J Reprod Med. 2004;49(12):983-985.
3. Stern PJ, Goldfarb CA. Images in clinical medicine. Interdigital pilonidal sinus. N Engl J Med. 2004;350(11): e10.
4. Kalsi JS, Arya M, Freeman A, Minhas S, Ralph DJ. A pilonidal sinus on the penis presenting with erectile dysfunction. Scand J Urol Nephrol. 2004; 38(1):92-93.
5. Gocmen A, Inaloz HS, Sari I, Inaloz SS. Endometriosis in the Bartholin gland. Eur J Obstet Gynecol Reprod Biol. 2004;114(1):110-111.
6. Binder SS. Endometriosis of the vulva and perineum: report of a case. Pac Med Surg. 1965;73(5):294-296.

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