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Surgical Treatment for Recurrent Refractory Skenitis

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We report a case of persistent skenitis that was initially misdiagnosed and treated as a urinary infection. Despite an adequate course of antibiotics, the symptoms failed to improve. The case was ultimately resolved with surgical intervention, which resulted in its prompt and complete resolution.
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Case Study
TheScientificWorldJOURNAL (2008) 8, 658–660
TSW Urology
ISSN 1537-744X; DOI 10.1100/tsw.2008.92
*Corresponding author.
©2008 with author.
Published by TheScientificWorld; www.thescientificworld.com
658
Surgical Treatment for Recurrent
Refractory Skenitis
E.P. Miranda1,*, D.C. Almeida1, G.P. Ribeiro2, J.M. Parente1,
and A.G. Scafuri1
1Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil; 2Faculty of
Medicine, Federal University of Vale do São Francisco, Petrolina, Brazil
E-mail: dudu308@yahoo.com.br; urologia@ufc.br
Received May 8, 2008; Revised June 6, 2008; Accepted June 17, 2008; Published July 13, 2008
We report a case of persistent skenitis that was initially misdiagnosed and treated as a
urinary infection. Despite an adequate course of antibiotics, the symptoms failed to
improve. The case was ultimately resolved with surgical intervention, which resulted in
its prompt and complete resolution.
KEYWORDS: skenitis, gynecologic infection, female prostate, sexually transmitted diseases
INTRODUCTION
The Skene's glands, also known as the lesser vestibular, periurethral glands, or paraurethral glands, are
structures located on the upper wall of the vagina, around the lower end of the urethra and are normally
neither seen nor felt, except in the presence of disease or infection. Close inspection will reveal the
pinpoint openings of these periurethral glands. These glands are homologous with the prostate gland in
males and seem to be responsible for female ejaculation[1].
CASE REPORT
A 49-year-old woman presented to our office complaining of dysuria over the past 4 weeks. She had an
episode of diverticulitis several months previously, treated with oral antibiotics. Before presenting to us,
she had gone to her gynecologist, who diagnosed lower urinary tract infection and prescribed
ciprofloxacin 1 g/day. She obtained relief of her symptoms for a couple of days, but they recurred and
persisted, despite another course of antibiotics.
She was sexually active with one partner and denied having any previous sexually transmitted
diseases. Sexual intercourse was sometimes uncomfortable, but rarely painful. Her menses were
somewhat irregular, but she stated that they had always been like that and that it “runs in her family”. She
denied having fever, weight loss, vaginal discharge, diarrhea, or constipation.
On physical examination, the patient had normal vital signs and was a moderately overweight woman
who appeared well and in no apparent distress. The abdomen was nondistended and nontender to
palpation. No inguinal lymphadenopathy was present. On pelvic inspection, she had no vaginal discharge
Miranda et al.: Surgical Treatment for Recurrent Refractory Skenitis TheScientificWorldJOURNAL (2008) 8, 658–660
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and no cervical motion tenderness was observed on digital exam. The rest of the physical examination
was unremarkable.
The urine pregnancy test was negative. Findings on wet-mount examination and urinalysis were
normal. Cultures for Neisseria gonorrhoeae, Chlamydia sp., and unspecific organisms were negative. The
patient was referred for pelvic ultrasonography, but the findings were unremarkable to her complaints.
Another culture was performed, which was also negative.
A bidigital examination was pursued and a 1- × 1-cm nodule was palpated in the left vaginal wall,
close to the opening of the urethra, more specifically at the topography of the left Skene’s gland. A
purulent discharge was noted at local compression and the diagnosis of skenitis was established (Fig. 1)
FIGURE 1. Local compression at the left vaginal wall, showing purulent discharge at the topography
of the left Skene’s gland opening.
Surgical treatment was scheduled and successfully performed. It consisted of a simple incision at the
opening of the gland to allow drainage of the secretion. There was no history of recurrence and the patient
related complete relief of her symptoms.
DISCUSSION
The Skene’s glands have a highly variable anatomy and in some extreme cases, appear to be entirely
absent. When infected, the Skene’s gland will become enlarged and tender, a condition known as skenitis.
Repeated infections may lead to increasing obstruction of the gland and result in a suburethral cyst or an
abscess cavity. Eventually, the cavity ruptures into the urethral lumen, creating a communication between
the urethral lumen and the suburethral cyst. Repeated pooling of urine into the suburethral cyst during
urination may lead to the formation of a urethral diverticulum[1].
The palpation of the Skene’s glands can be done by rotating the internal fingers upward and palpating
the labia bilaterally; by applying pressure with the index finger on the anterior vaginal wall, a discharge
can be obtained[2,3].
Miranda et al.: Surgical Treatment for Recurrent Refractory Skenitis TheScientificWorldJOURNAL (2008) 8, 658–660
660
In acute gonorrhea, these glands are almost always infected. Cultures, particularly for gonorrhea,
should thus be obtained. Some reports showed that α1 blockers and effective antibiotics were considered
an ideal choice of treatment for female skenitis. Good options for antibiotics would include those most
helpful for treating urethritis: cefixime 400 mg orally in a single dose, ceftriaxone 125 mg i.m. in a single
dose, ciprofloxacin 500 mg orally in a single dose, or ofloxacin 400 mg orally in a single dose combined
with azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice a day for 7 days[4].
The surgical cases can be resolved with a simple incision and drainage of the gland, which generally
result in complete resolution. Topical anesthetic (20% benzocaine, or “Hurricaine”) can be applied to the
cyst with a cotton-tipped applicator and allowed to sit for 3–4 min. A single stab wound by a scalpel
opens the abscess and allows the drainage of the pus[5].
There may be involvement of these glands in vaginal or vulvar masses. Periurethral lesions occur in
almost one-quarter of women with genital masses. The differential diagnosis of an anterior vaginal wall
mass should include urethral diverticulum, Skene gland abscess, ectopic ureterocele, Gartner duct cyst,
müllerian remnant cyst, and vaginal inclusion cyst. Symptoms vary in women with periurethral masses:
pain, dyspareunia, dysuria, and other urinary symptoms are the most common, and will resolve after
successful excision of the lesion[4,6].
The reduced number of reported cases of this entity, with only a few descriptions in the literature, led
us to believe that this disease is actually underestimated. As the clinical aspects of skenitis are highly
variable and are not specific of this condition, it is possible that many misdiagnosed cases are treated as
urinary infection and as they obtain complete resolution, surgical treatment is rarely necessary.
ACKNOWLEDGMENTS
We hereby acknowledge that all authors have significantly contributed to the elaboration of this work,
either to the conduction of the case or to the preparation of this manuscript. Informed consent was
obtained from the patient and her identity remains unrevealed. No conflicts of interest are attached to this
paper.
REFERENCES
1. Aspera, A., Rackley, R., and Vasavada, S. (2002) Contemporary evaluation and management of the female urethral
diverticulum. Urol. Clin. North Am. 29(3), 617–624.
2. Zaviacic, M., Jakubovská, V., Belosovic, M., and Breza, J. (2000) Ultrastructure of the normal adult human female
prostate gland (Skene's gland). Anat. Embryol. (Berl.) 201, 51–61.
3. Jannini, E., Simonelli, C., and Lenzi, A. (2002) Disorders of ejaculation. J. Endocrinol. Invest. 25(11), 1006–1019.
4. Izquierdo, C., Rodríguez, P., Sabanés, M.E., Navarro, F., and Sánchez, F. (1996) Gardnerella vaginalis skenitis.
Enferm. Infecc. Microbiol. Clin. 14(3), 199–200.
5. Gallo, D. (1964) Skenitis and stenosis of the urinary meatus. Rev. Mex. Urol. 23, 89–103.
6. Durel, P. (1951) Broad exposure for skenitis and bartholinitis. Gynecol. Prat. 2(3), 389–392; English transl., 393–395.
This article should be cited as follows:
Miranda, E.P., Almeida, D.C., Ribeiro, G.P., Parente, J.M., and Scafuri, A.G. (2008) Surgical treatment for recurrent refractory
skenitis. TheScientificWorldJOURNAL: TSW Urology 8, 658–660. DOI 10.1100/tsw.2008.92.
... [1][2] No entanto, alguns autores defendem que não se tratará somente de uma situação pouco comum, mas também pouco descrita na literatura e subdiagnosticada. 3 Adicionalmente, esta é uma condição clínica cujos sinais e sintomas apresentam uma elevada variabilidade e baixa especificidade, dificultando ainda mais a sua identificação. 3 O diagnóstico de abcesso das glândulas de Skene tem como pedra basilar uma anamnese completa e subsequente observação clínica, dirigida e cuidada. Em casos de dúvida poderão ser utilizados exames complementares, nomeadamente a ecografia ou a resso- ...
... 3 Adicionalmente, esta é uma condição clínica cujos sinais e sintomas apresentam uma elevada variabilidade e baixa especificidade, dificultando ainda mais a sua identificação. 3 O diagnóstico de abcesso das glândulas de Skene tem como pedra basilar uma anamnese completa e subsequente observação clínica, dirigida e cuidada. Em casos de dúvida poderão ser utilizados exames complementares, nomeadamente a ecografia ou a resso- ...
... As lesões periuretrais ocorrem em cerca de um quarto das mulheres com massas genitais. 3 O diagnóstico diferencial de massas localizadas na parede vaginal anterior poderá incluir múltiplas patologias, nomeadamente divertículos uretrais, ureterocelos, prolapsos vaginais, quistos e abcessos. [2][3] As glândulas de Skene, também designadas glândulas periuretrais, localizam-se adjacentemente aos dois terços distais da uretra, sendo consideradas homólogas às glândulas prostáticas no homem. ...
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... According to Miranda, Almeida, Ribeiro, Parente and Scafuri (2008), periurethral diverticulum refers to a cystic lesion appearing on the anterior wall of the urethra which creates a ball-shaped mass that is concealed and has connection to the urethra tube. This excess mass provides shelter for bacteria that colonise the urethral area. ...
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