A woman comes with complaints of pain and swelling in the perineal area. She also has complaints of difficulty in walking and sitting. She gives a history of multiple sexual partners. On examination, a tender swelling is seen with redness on the labia, as shown in the image given below. What is the most likely diagnosis? La d

Correct Answer: C. Bartholin abscess

Bartholin abscess presents with acute onset pain, swelling, and redness in the labia majora at the posterolateral aspect of the vaginal introitus—the classic location of Bartholin glands (situated at 4 and 8 o'clock positions). The patient's triad of perineal pain, difficulty walking/sitting, and localized tender swelling with erythema on the labia is pathognomonic. Bartholin gland infections arise when the duct becomes obstructed, leading to cyst formation and secondary bacterial infection (commonly Staphylococcus aureus, Escherichia coli, or Neisseria gonorrhoeae). The history of multiple sexual partners increases STI risk, but the acute presentation with localized abscess formation at the gland site—not diffuse vulvitis—is the discriminating feature. On examination, a unilateral, fluctuant swelling at the posterolateral vulva with surrounding erythema and tenderness is diagnostic. Management includes incision and drainage with marsupialization (Word catheter or formal marsupialization) to prevent recurrence, along with broad-spectrum antibiotics. This is the most common cause of vulvar abscess in reproductive-age women in Indian clinical practice.

Why the other options are wrong

A. Chlamydial infection — Chlamydia trachomatis causes cervicitis, urethritis, and pelvic inflammatory disease with mucopurulent cervical discharge and lower abdominal pain—not localized vulvar abscess. While Chlamydia may be a secondary pathogen in Bartholin abscess, it does not cause the acute, fluctuant, posterolateral labial swelling seen here. Chlamydial vulvitis is rare and presents as diffuse inflammation, not a discrete abscess. B. Genital Tuberculosis — Genital TB is a chronic disease affecting the endometrium and fallopian tubes primarily, presenting with infertility, amenorrhea, and chronic pelvic pain—not acute vulvar abscess. TB rarely involves Bartholin glands and presents insidiously over months to years with constitutional symptoms. The acute presentation with localized fluctuant swelling rules out TB entirely. D. Herpes infection — Herpes simplex virus causes painful vesicles and ulcers on the vulva with systemic symptoms (fever, malaise, lymphadenopathy) and a prodrome of tingling. It does not form a single, localized, fluctuant abscess at the posterolateral vulva. Herpes presents as multiple painful ulcers scattered across the vulva, not a discrete glandular swelling.

High-Yield Facts

Mnemonics

BABS (Bartholin Abscess Basics) Back of vulva (posterolateral) | Acute swelling + pain | Broad-spectrum antibiotics + drainage | Single fluctuant mass. Use when localizing vulvar pathology. Position Memory: 4 & 8 o'clock Bartholin glands sit at 4 and 8 o'clock on the vulva (like clock hands). Abscess = swelling at these exact positions. Differentiates from diffuse vulvitis (herpes, chlamydia spread across vulva).

NBE Trap

NBE pairs multiple sexual partners with STI diagnosis (Chlamydia, herpes) to distract from the anatomically localized, posterolateral swelling that is pathognomonic for Bartholin abscess. The history of sexual exposure is a red herring; the clinical examination finding (discrete abscess at gland site) is the true discriminator.

Clinical Pearl

In Indian outpatient gynecology, Bartholin abscess is the most common cause of acute vulvar swelling in reproductive-age women. Many patients delay seeking care due to embarrassment; early recognition and marsupialization prevent recurrent infections and chronic cyst formation. Word catheter placement is the preferred outpatient technique in resource-limited Indian settings.

_Reference: DC Dutta's Textbook of Obstetrics (Gynecology section), Ch. on Vulval Disorders; OP Ghai's Essential Obstetrics, Vulval Pathology_