36 years old female patient referred from Gynecologist with complaints of Urethral discomfort and pus discharge per Urethra, which were recurring symptoms since over past several months. She had visited several healthcare facilities in UAE during the past year to seek diagnosis & treatment for her bothersome complaints. During all those visits she underwent clinical evaluation/examination, various lab tests etc. & was prescribed antibacterial medication each time for the diagnosis of Recurrent STI Vulvovaginitis/Urethritis but to no permanent resolve. Clinical Findings: • Pus discharge from external urethral meatus i.e. especially during palpation of distal anterior vaginal wall. • Left postero-lateral Para-Urethral cystic bulge. Investigations & Findings: • Urethral pus swab culture/sensitivity: Pseudomonas Species, Klebsiella Pneumoniae & E. coli etc. (i.e. Repeat Urethral pus swab cultures spanning over 4months of conservative treatment). • Pelvic & Trans-Vaginal USG: Normal • MRI Pelvis with IV contrast: Postero-lateral, Para-Urethral cystic lesion, saddling the distal Urethra & displacing the external urethral meatus with no obvious communication with Urethral lumen.
Diagnosis: Differential diagnosis of the following conditions being considered, • Urethral Diverticulum • Para-Urethral Skene’s gland infected cyst/abscess Management: • Initial treatment with antibacterial medication/antibiotic course (i.e. as per available pus culture/sensitivity antibiogram). • Surgical excision of Para-Urethral cystic lesion coupled with intra-operative Urethrocystoscopy. Post-operative Course & Follow Up: • Discharged on one week of indwelling urethral Foley’s catheter after uneventful post- operative recovery. • Passing urine well without any complaints & no bothersome Urethral symptoms etc. (i.e. Follow up after Urethral Foley’s catheter removal. Histopathology: • Para-Urethral Skene’s glands with chronic inflammation & No atypia.)
Review Of Literature And Discussion: Skene’s glands were first described by Regnier de Graaf (1641–1693) but are named after the Scottish gynecologist Alexander Skene, who published his findings in the Western medical literature in 1880. The Skene’s glands, or Para-urethral glands, are found in the caudal two-thirds of the urethra, mainly in the dorsal and lateral mucosal stroma. They are the female homologues of the prostate gland in the male and arise from the urogenital sinus. Wernert et al. presented a histological study and found that these glands are not always present and were found in only two-thirds of the 33 women they studied. Abscesses of the Skene’s gland most commonly present in the third to fourth decades, and it is uncommon to find Skene’s gland abscesses in pediatric patients. Presenting symptoms of Skene’s gland abscess include urethral pain, dysuria, dyspareunia, presence of an asymptomatic mass, recurrent urinary tract infection, urethral pus discharge, and voiding symptoms. Infection of the gland by bacteria leads to inflammatory obstruction of the Para- urethral ducts, which give rise to the formation of a cyst or abscess. Bacteria commonly associated with a Skene’s gland abscess include Escherichia coli, Neisseria gonorrhoeae, vaginal flora, and other coliform bacteria. Antibiotic therapy is typically initiated to cover these common pathogens. If a response is seen to antibiotic therapy but symptoms recur, then a repeat course is given. If there is no response to antibiotics, then surgical therapy is offered. It is reasonable to consider surgical intervention after a failure or recurrence of symptoms following one or two courses of antibiotics if the patient is symptomatic and appropriately counselled. Surgical excision, marsupialization, and needle aspiration have all been described for the surgical management of a Skene’s gland abscess. Performed correctly, Surgical excision has over 88% success in avoiding recurrence. Reviewed By: Dr. Amod Gajanan Tilak Dr. Monica Chauahn Specialist Urologist Specialist Gynecologist Burjeel Day Surgery Center Burjeel Day Surgery Center Abu Dhabi Abu Dhabi