
==== Front
J Am Coll Emerg Physicians Open
J Am Coll Emerg Physicians Open
10.1002/(ISSN)2688-1152
EMP2
Journal of the American College of Emergency Physicians Open
2688-1152
John Wiley and Sons Inc. Hoboken

10.1002/emp2.13262
EMP213262
Images in Emergency Medicine
Images in Emergency Medicine
Elderly woman with clitoral swelling and pain
BARDEN et al.
Barden Matthias MD https://orcid.org/0000-0002-1731-4933
1 mbarden@eisenhowerhealth.org

Reyna Roberto MD 1
Hariri Lana MD 1
1 Department of Emergency Medicine Eisenhower Health Rancho Mirage Rancho Mirage California USA
* Correspondence
Matthias Barden, Department of Emergency Medicine, Eisenhower Health, Rancho Mirage, CA, USA.
Email: mbarden@eisenhowerhealth.org

19 9 2024
10 2024
5 5 10.1002/emp2.v5.5 e1326208 7 2024
16 7 2024
© 2024 The Author(s). Journal of the American College of Emergency Physicians Open published by Wiley Periodicals, Inc. on behalf of American College of Emergency Physicians.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

source-schema-version-number2.0
cover-dateOctober 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:20.09.2024
Barden M , Reyna R , Hariri L . Elderly woman with clitoral swelling and pain. JACEP Open. 2024;5 :e13262. 10.1002/emp2.13262
==== Body
pmc1 CASE PRESENTATION

A 77‐year‐old female presented to our community‐based emergency department complaining of clitoral swelling and pain (Figure 1). She reported a 2‐week history of gradually increasing enlargement and discomfort of the area. One month prior to the onset of these symptoms, she had undergone a urethral bulking agent injection by a urogynecologist at a different health system to treat urinary stress incontinence with polyacrylamide hydrogel (Bulkamid). 1

FIGURE 1 Clinical photograph of enlarged and inflamed clitoris.

She was awaiting a follow‐up appointment with her urogynecologist but decided to seek care in the emergency department instead once she felt the pain was no longer tolerable. In the emergency department, point‐of‐care ultrasound was performed showing a localized collection of heterogeneous nonvascular debris consistent with abscess formation, as opposed to solid or cystic mass (Figure 2 and video file supplemental data). 2

FIGURE 2 Ultrasound image showing localized heterogeneous debris consistent with abscess.

2 DISCUSSION

2.1 Diagnosis: Clitoral abscess after urethral bulking agent injection

The history and physical examination along with point‐of‐care ultrasound led us to our clinical impression of clitoral abscess. The local on‐call gynecologist was consulted and recommended bedside incision and drainage in the emergency department. A small incision was made under local anesthetic and resulted in approximately 6 mL of purulent drainage, which was sent for culture. The patient was discharged home on oral antibiotics with a plan for outpatient urogynecology specialty clinic follow up.

The culture later resulted in multidrug resistant expanded spectrum beta‐lactamase positive Escherichia coli, which was susceptible to the trimethoprim/sulfamethoxazole she had been prescribed. The patient was contacted over the telephone the week following her emergency department visit and reported resolution of the clitoral pain and swelling.

Clitoral abscess is a rare clinical disorder that tends to develop related to pilonidal disease or trauma. 3 In this case, the abscess was felt most likely to represent a complication of her recent ureteral bulking agent injection. Although it is possible, the abscess developed instead as a result of the patient's other risk factors such as her history of diabetes, obesity, and recurring urinary tract infection.

Urethral bulking agent injections have been shown to carry lower rates of complications than more invasive surgeries for urinary stress incontinence. 4 However, known complications of urethral bulking agent injections include periurethral abscess and sterile pseudo‐abscess formation. 5 Clitoral abscess has not previously been reported as a complication of ureteral bulking agent injection. 6

Supporting information

Supporting information

Supporting information
==== Refs
REFERENCES

1 Martan A , Masata J , Svabík K , Krhut J . Transurethral injection of polyacrylamide hydrogel (Bulkamid®) for the treatment of female stress or mixed urinary incontinence. Eur J Obstet Gynecol Reprod Biol. 2014;178 :199‐202.24802188
2 Squire BT , Fox JC , Anderson C . ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections. Acad Emerg Med. 2005;12 (7 ):601‐606.15995090
3 Zeitoun J , Pizzoferrato AC , Philippart J , Gaichies L , Benoist G , Fauvet R . Clitoral abscess, a rare cause of gynecological emergency: diagnosis and management. Eur J Obstet Gynecol Reprod Biol. 2020;252 :625‐627.32593473
4 Kocjancic E , Mourad S , Acar Ö . Complications of urethral bulking therapy for female stress urinary incontinence. Neurourol Urodyn. 2019;38 (Suppl 4 ):S12‐S20.31066956
5 Gopinath D , Smith AR , Reid FM . Periurethral abscess following polyacrylamide hydrogel (Bulkamid) for stress urinary incontinence. Int Urogynecol J. 2012;23 (11 ):1645‐1648.22527560
6 Kirchin V , Page T , Keegan PE, Atiemo K, Cody JD, McClinton S . Urethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev. 2017;7 (7 ):CD003881.28738443
