**12. Sexual violence**

Abscesses that rupture spontaneously are treated by warm sitz bath. Gland excision is not recommended for Bartholin's abscess because of the risk of spread of infection which may

Another less common vulvar abscess is that involving the Skene's gland. Treatment basically

Toxic shock syndrome is a rare entity primarily occurring in menstruating women and caused by exotoxins produced by penicillinase-producing non invasive Staphylococcus aureus of phage type 1. It is associated with use of super absorbent tampons, especially if left in place for long. Tampon use may also excoriate the cervical and vaginal mucous membranes, thereby

Non-menstrual toxic shock syndrome has been reported with prolonged use of contraceptive diaphragm or sponge [48], after delivery, laser therapy for condylomata acuminatum [49] and

Toxic shock syndrome can also be caused by some streptococcus species, including Strepto‐

The clinical manifestations of toxic shock syndrome are diverse and these often develop rapidly in otherwise healthy persons. These include sudden onset of high fever, hypotension, and associated symptoms like vomiting, diarrhoea, myalgia, abdominal pain, and headache. A characteristic "sunburn-like" rash, a diffuse maculopapular erythroderma, appears over the face, trunk and proximal extremities over a period of 5-14 days, which later desquamates, especially over the palms and soles during convalescence. Multi-systemic involvement is typical and these include coagulopathy, renal, hepatic, muscular, cardiovascular, neurological

On taking a history, ask the patient if she is menstruating or using tampons. A vaginal examination should be performed and any foreign body in the vagina such as tampon or

The diagnosis of toxic shock syndrome is usually clinical. A full septic and biochemical screen should be done to exclude multiorgan failure. Isolation of the exotoxin for Staphylococcus

Treatment entails aggressive supportive therapy, preferably in an intensive care unit. Fluid resuscitation is necessary, and vasopressors, packed red cells and coagulation factors, me‐ chanical ventilation and haemodialysis may be required. Antibiotics, given intravenously, are used for 10-14 days to eradicate the organism. Protein synthesis inhibitors such as clindamycin which suppress toxin production are more effective than cell wall active agents like betalactams. Cephalosporins or beta-lactamase-resistant penicillins like nafcillin or oxacillin, and vancomycin (for penicillin-allergic patients) may also be used. Since toxic shock syndrome is

coccus viridans which causes a more fulminant disease with high mortality.

result following surgery in an inflamed hyperaemic tissue environment [47].

follows the same principles as that for Barthoin's abscess.

**11. Toxic shock syndrome**

44 Contemporary Gynecologic Practice

encouraging absorption of the exotoxin.

non-gynaecological surgery.

and respiratory systems.

aureus is pathognomonic.

contraceptive device should be removed.

Rape definitions vary from country to country, but generally regarded as the physically forced entry or the otherwise coerced penetration of the mouth, vulva, vagina or anus with a penis, other body part or object. It is an act of sexual violence. It can result in serious short and longterm physical, mental, sexual and reproductive health problems for victims and their families and can lead to social and economic costs.

Health consequences may include headache, back pain, abdominal pain, gastrointestinal disorders, limited mobility and poor overall health. Non fatal and fatal injuries can also result.

Rape can result in unwanted pregnancies, gynaecological problems, induced abortions, sexually transmitted infections, including human immunodeficiency virus (HIV) and hepatitis B infections. Mental disorders like post-traumatic stress disorder, sleep difficulties, depression, suicidal tendencies and drug and alcohol abuse can arise.

Some gynaecologists hardly receive proper orientation or training in managing intimate partner violence as part of their medical training and therefore tend to underestimate the extent of the problem and feel insufficiently skilled to deal with it [50]. Treatment here typically involves dealing with coital lacerations, STDs, including HIV and hepatitis-B post-exposure prophylaxis, tetanus prophylaxis, and emergency contraception to prevent unwanted preg‐ nancy. Due to the extent of coital injuries, especially when foreign objects are used, emergency laparotomy may be required.

It is crucial that advice is sought from the police or sexual assault referral centre before undertaking any examination for forensic reasons, unless it is life-saving. Pictures of the victim, multiple swabs and aspirations from body cavities and parts, and a whole lot more may need to be taken. A checklist may be required to follow due process on the management of such cases, as well as employing the services of a clinical psychologist or psychiatrist for long-term management.
