What is the recommended management for a vulvar abscess in an otherwise healthy adult female?

Vulvar Abscess Management

Primary Treatment: Incision and Drainage

Incision and drainage is the cornerstone of treatment for all vulvar abscesses and must be performed urgently to prevent progression to necrotizing fasciitis and systemic sepsis. 1, 2

Surgical Technique

• Make the incision as close as possible to the affected area while ensuring complete drainage 1
• Thoroughly evacuate all pus and probe the cavity to break up any loculations, as inadequate drainage leads to recurrence rates up to 44% 1, 2
• For large abscesses (>5 cm), use multiple counter-incisions rather than a single long incision to prevent step-off deformity and delayed healing 1, 2
• Consider placing a drain (such as Hemovac) for abscesses >5 cm to ensure continued drainage 3
• Primary suture under antibiotic cover is an alternative approach that reduces hospital stay from 7 to 2 days and healing time from 18 to 7 days compared to conventional open treatment 4

Timing of Intervention

• Emergency drainage within hours is mandatory for patients with: 1
  • Sepsis, severe sepsis, or septic shock
  • Immunosuppression or diabetes mellitus
  • Diffuse cellulitis extending beyond the vulva
• For stable patients without these risk factors, perform drainage within 24 hours 1

Antibiotic Therapy

When to Use Antibiotics

Antibiotics are NOT routinely required after adequate surgical drainage in otherwise healthy patients with simple vulvar abscesses. 1, 2

Antibiotics ARE indicated when: 1, 2, 5

• Systemic signs of infection present (temperature >38.5°C, heart rate >110 bpm, WBC >12,000 cells/µL)
• Significant surrounding cellulitis (erythema/induration extending >5 cm)
• Incomplete source control or inadequate drainage
• Patient has diabetes mellitus, immunosuppression, or other significant comorbidities
• Abscess size >5 cm 3, 6

Antibiotic Selection

For vulvar location specifically, use empiric broad-spectrum coverage for polymicrobial flora including MRSA: 2, 3, 5

First-line oral regimen (outpatient):

• Clindamycin 300-450 mg PO every 6-8 hours PLUS trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 double-strength tablets twice daily 2, 5
• Alternative: Levofloxacin 500 mg daily PLUS metronidazole 500 mg every 8 hours 3

Intravenous regimen (inpatient):

• Gentamicin PLUS clindamycin 3
• Alternative: Levofloxacin PLUS metronidazole 3

Duration: 7-10 days for simple cases; up to 7 days for immunocompromised patients 2

MRSA Considerations

• MRSA is isolated from 64% of vulvar abscesses and should be empirically covered in all cases requiring antibiotics 5
• TMP-SMX or clindamycin provide adequate MRSA coverage 2, 5

Post-Operative Care

• Wound packing after drainage remains controversial and may be painful without adding benefit 7, 1
• Simply covering with a dry dressing is usually effective 2
• If primary suture technique is used, give single-dose clindamycin at time of closure 4

Follow-Up and Monitoring

• Routine imaging after drainage is not required 1
• Patients with ongoing signs of infection beyond 7 days warrant diagnostic re-evaluation including repeat cultures and imaging 1, 2
• Follow-up within 48-72 hours to assess clinical response 3

Risk Factors and Special Populations

High-risk patients requiring more aggressive management: 6, 5

• Diabetes mellitus (present in 60.7% of hospitalized patients) 3
• Obesity (BMI directly proportional to abscess size and ICU admission risk) 6
• Multiple comorbidities increase length of hospitalization 6

Inpatient admission criteria: 5

• Medical comorbidities (diabetes, hypertension)
• Abscess size >5 cm (mean 5.2 cm in admitted patients)
• Elevated WBC ≥12,000/mm³
• Serum glucose >200 mg/dL
• Signs of systemic illness or sepsis

Critical Pitfalls to Avoid

• Never treat with antibiotics alone without drainage - this leads to treatment failure and progression to necrotizing infection 1, 2
• Do not delay drainage while waiting for imaging or laboratory results - clinical diagnosis is sufficient for typical presentations 1, 2
• Ensure complete drainage of all loculations - inadequate drainage is the primary cause of recurrence 1, 2
• Do not underestimate the potential for rapid progression - the subcutaneous anatomy of the vulva facilitates rapid spread to other tissues 8