How should a vulvar abscess be managed, including incision and drainage, appropriate antibiotic selection (with MRSA coverage if risk factors), analgesia, wound care, and follow‑up?

Management of Vulvar Abscess

Incision and drainage is the cornerstone of treatment for all vulvar abscesses, and antibiotics with MRSA coverage (such as trimethoprim-sulfamethoxazole or clindamycin) should be strongly considered given that MRSA accounts for approximately 64% of cultured vulvar abscesses. 1

Immediate Surgical Management

• Incision and drainage is mandatory for every vulvar abscess—this is the primary treatment and must not be delayed. 2
• The incision should be adequate to ensure complete drainage; inadequate drainage is the principal cause of recurrence. 3
• After incision, thoroughly evacuate all purulent material and break up any loculations, as failure to address loculations increases recurrence risk up to 44%. 3
• For abscesses larger than 5 cm, consider placement of a drain (such as a Hemovac) to maintain adequate drainage. 4
• Primary suture under antibiotic cover is an alternative approach that significantly reduces hospital stay (median 2 days vs. 7 days) and healing time (median 7 days vs. 18 days) compared to conventional open treatment with wet dressings, without increasing recurrence rates. 5

Antibiotic Selection

Empiric Therapy (Outpatient)

• For simple vulvar abscesses after adequate drainage in immunocompetent patients without systemic signs, oral antibiotics with MRSA coverage are recommended: 2, 1

  • Trimethoprim-sulfamethoxazole 1–2 double-strength tablets PO twice daily 2
  • Clindamycin 300–450 mg PO three times daily 2
  • Doxycycline 100 mg PO twice daily (avoid in pregnancy) 2

• These regimens provide coverage for both MRSA (present in 64% of vulvar abscesses) and streptococci. 1, 2

Indications for Inpatient IV Antibiotics

Admit for IV antibiotics if any of the following are present: 1, 6

• Medical comorbidities: diabetes mellitus (odds ratio 2.29), hypertension, or immunosuppression 1, 6
• Abscess size ≥5 cm 1
• Signs of systemic illness: fever, elevated white blood cell count ≥12,000/mm³, serum glucose >200 mg/dL 1
• Extensive surrounding cellulitis 2
• Incomplete source control after initial drainage 2, 3

Empiric IV Antibiotic Regimens

• For patients requiring hospitalization with systemic signs or extensive cellulitis, use broad-spectrum coverage: 2, 3

  • Vancomycin 15–20 mg/kg IV every 8–12 hours (for MRSA coverage) 2, 7
  • PLUS coverage for Gram-negatives and anaerobes (vulvar abscesses are frequently polymicrobial): 2, 3
    • Piperacillin-tazobactam 3.375 g IV every 6 hours 3
    • OR Cefazolin 1–2 g IV every 8 hours PLUS metronidazole 500 mg IV every 8 hours 8

• Alternative single-agent regimen: Linezolid 600 mg IV/PO twice daily (covers MRSA and streptococci but lacks Gram-negative and anaerobic coverage). 2

Duration of Antibiotic Therapy

• After adequate drainage in immunocompetent patients: 5–7 days of oral antibiotics 2, 4
• For patients with diabetes, immunosuppression, or extensive cellulitis: 7–10 days 2, 3
• For complicated cases with incomplete drainage or recurrence: up to 2 weeks 3

Analgesia

• Provide adequate pain control with NSAIDs (ibuprofen 600 mg PO every 6 hours) or acetaminophen (1000 mg PO every 6 hours). 4
• For severe pain, consider short-term opioid therapy (e.g., oxycodone 5–10 mg PO every 4–6 hours as needed). 4

Wound Care

• If primary suture is performed: Keep the wound clean and dry; remove sutures at 7–10 days. 5
• If open drainage is performed: Daily wound care with normal saline irrigation or dilute hydrogen peroxide; avoid tight packing as it increases pain without improving healing. 3, 4
• Sitz baths 2–3 times daily promote comfort and drainage. 4

Follow-Up

• Outpatient follow-up within 48–72 hours to assess response to treatment and ensure adequate drainage. 4, 1
• Screen for underlying diabetes mellitus (fasting glucose, HbA1c) in all patients, as diabetes is present in 45–61% of vulvar abscess cases and is a major risk factor for recurrence. 1, 6, 3
• Routine imaging is not required after drainage unless there is concern for recurrence, non-healing wound, or suspected deeper extension. 3
• Educate patients to return immediately for fever, worsening pain, spreading erythema, or purulent drainage. 4

Critical Pitfalls to Avoid

• Do not rely on antibiotics alone without drainage—this will lead to treatment failure. 2
• Do not underestimate MRSA prevalence—empiric coverage is essential in populations with high MRSA rates (>10–15%). 1, 2
• Do not perform inadequate incision or drainage—this is the leading cause of recurrence (up to 44%). 3
• Do not delay surgical intervention in patients with systemic signs, diabetes, or large abscesses (≥5 cm)—these patients require urgent drainage and IV antibiotics. 1, 6, 3
• Obesity (elevated BMI) is directly proportional to abscess size and risk of ICU admission—maintain a low threshold for admission in obese patients. 6