Introduction
Bartholin gland cysts or abscesses develop in approximately 2% of all women. These lesions can cause extreme pain and limitation of activity because of expansion or infection. The glands ' secretions provide some moisture for the vulva but are not needed for sexual lubrication. Removal of a Bartholin gland does not compromise the vestibular epithelium or sexual functioning.
The Bartholin glands are located at 5 o 'clock and 7 o 'clock at the vaginal introitus and normally cannot be palpated. Bartholin gland cysts develop from dilation of the duct after blockage of the duct orifice. These lesions usually are 1 to 3 cm in diameter and asymptomatic. When symptoms occur, the patient may report vulvar pain, dyspareunia, inability to engage in sports, and pain during walking or sitting.
When the Bartholin cyst become an abscess, patients may experience severe dyspareunia, difficulty in walking or sitting, and vulvar pain. Patients can develop a large, tender mass in the vestibular area with associated vulvar erythema and edema. The abscess usually develops over 2 to 4 days and can become larger than 8 cm in diameter. The condition can be so painful that the patient is incapacitated. The abscess tends to rupture and drain after 4 to 5 days.
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The best method for treating a cyst or abscess is one that preserves physiologic function with a minimum of scarring. Simple incision and drainage has a recurrence rate of 70% to 80%. When treating an abscess, obtain cultures for chlamydia and gonorrhea, and prescribe oral broad-spectrum antibiotics. Diabetic patients are more susceptible to necrotizing infections and need careful observation. Consider inpatient management of women with severe infections.
Simple incision and drainage provides prompt symptomatic relief, but recurrence is common. Treatment is not contraindicated in pregnant women, although the increase in blood flow to the pelvic area during pregnancy may lead to excessive bleeding from the procedure. If treatment is necessary because of an abscess, local anesthesia and most broad-spectrum antibiotics are safe.
In 1964, Dr. B. A. Word introduced a simple fistulization technique using a small, inflatable, self-sealing, bulb-tipped catheter. Early abscesses can be treated with sitz baths until the abscess points, making incision and definitive treatment easier. Instruct the patient to return in 4 weeks for a follow-up examination or sooner if she experiences discomfort, swelling, or other symptoms of infection. Patients may use ibuprofen (400 to 800 mg taken every 6 hours) for discomfort in the immediate postoperative period, and they should refrain from intercourse during the healing time to prevent displacement of the catheter. The catheter is removed by deflating the balloon, and over time, the resulting orifice will decrease in size and become unnoticeable.
Other options for treatment of a Bartholin gland abscess include the marsupialization or "window " procedure, carbon dioxide laser excision, and surgical excision. The marsupialization procedure is a relatively straightforward procedure that can be performed in the office, emergency department, or outpatient surgical suite in about 15 minutes using local anesthesia. It can be used as primary treatment or can be used if a cyst or abscess recurs after treatment with a Word catheter. The recurrence rate after marsupialization is 10% to 15%.
A cyst that has recurred several times despite office-based treatment may require excision. Excision of a Bartholin gland cyst is an outpatient surgical procedure that probably should be performed in an operating suite by an experienced physician because of the possibility of copious bleeding from the underlying venous plexus. Excision is usually performed under general anesthesia or with a pudendal block. It can result in intraoperative hemorrhage, hematoma formation, secondary infection, and dyspareunia as a result of scar tissue formation.
Equipment
- Prep solution (see Appendix E)
- Anesthetic solution
Word Catheter Technique
- Word catheter
- 18- or 20-gauge needle and 5-mL syringe plus water or gel for inflation of catheter tip
- No. 11 scalpel
- Hemostat (for breaking up loculations)
- Culture media for gonorrhea, chlamydia, and routine cultures
- Silver nitrate sticks
- Gauze pads
Marsupialization
- No. 11 scalpel
- Delayed-absorbable suture (3-0 or 4-0) on small cutting needle
- Small needle driver
- Scissors
- Hemostats
- Forceps
- Culture media
- Silver nitrate sticks
- Gauze pads
Indications
- Enlarged or painful Bartholin cyst or abscess
Contraindications
- Surgery on an acutely, severely inflamed abscess (relative contraindication)
- Asymptomatic cysts (relative contraindication)
- Latex allergy (e.g., to Word catheter)
The Procedure
Word Catheter
Step 1
Explain the procedure of fistulization with a Word catheter and obtain informed consent. Test the device by inserting the needle into the center of the base of the Word catheter and inflate the bulb.
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Step 2
Apply field block anesthesia (see Field Block Anesthesia) and prep the area (see Appendix E).
- PITFALL: Inject under and around the abscess, not into it. Lidocaine injected into the cavity is trapped and cannot provide anesthesia. Injection into the abscess can cause increased internal pressure and outward rupture of the abscess.
- Pearl: It may cause less pain to simply incise without anesthesia an abscess that has very attenuated overlying skin.
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Step 3
Use a stab incision with a no. 11 scalpel blade to make a 1.0- to 1.5-cm-deep opening into the cyst, preferably just inside or, if necessary, just outside the hymenal ring. Consider testing abscess contents for chlamydia and gonorrhea.
- PITFALL: Do not make the incision on the outer labium minus or labium majus. The resulting scar may cause pain, a poor cosmetic result, or a permanent fistula.
- PITFALL: Do not extend the incision beyond the width of the blade, or the catheter will require a retention stitch.
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Step 4
Break up loculations with a hemostat or similar instrument.
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Step 5
Insert the Word catheter. After the tip is inserted through the incision, the bulb is inflated with water or lubricating gel, and the free end of the catheter is tucked up into the vagina.
- PITFALL: Use water or gel rather than air to prevent premature deflation of the balloon.
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Step 6
Leave the catheter in place for up to 4 weeks to permit complete epithelialization of the new tract. The patient may take daily baths or showers and gently cleanse the area with soap and water. Contact the patient if tests for sexually transmitted diseases are positive.
- PITFALL: The catheter frequently falls out. Placement of a vaginal suture into vulvar skin and tied to the catheter can help hold those that recurrently fall out.
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Marsupialization
Step 1
For marsupialization, wash the area with povidone-iodine solution, and make a fusiform incision adjacent to the hymenal ring.
- PITFALL: Do not make the incision on the outer labium minus or labium majus. The resulting scar may cause pain, a poor cosmetic result, or a permanent fistula.
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Step 2
The incision should measure about 2 cm long and should be deep enough to enter the cyst. Remove an oval wedge of vulvar skin and the underlying cyst wall. The cyst or abscess will drain once it has been unroofed. Break up loculations inside the cyst, if present.
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Step 3
Suture the cyst wall to the adjacent vestibular skin using interrupted 3-0 or 4-0 absorbable (Vicryl) sutures. The new tract will slowly shrink over time and epithelialize, forming a new, larger duct orifice.
- PITFALL: If bleeding occurs, use suture placement or direct pressure for hemostasis of the skin edge.
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Complications
- Nonhealing
- Recurrent abscess
- Scarring
- Septic shock (with incision of abscess)
Pediatric Considerations
This problem is rarely encountered in the pediatric population.
Postprocedure Instructions
The patient should avoid tub baths and intercourse until the tissues heal. The patient can resume other usually activities.
Coding Information and Supply Sources
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 56420 I&D of abscess of Bartholin gland $340.00 10 56440 Marsupialization of Bartholin gland cyst $872.00 10 56740 Excision of Bartholin 's gland or cyst $992.00 10 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.I&D, incision and drainage.
Supply Sources
- A standard office surgical tray used for simple surgical procedures is described in Appendix G.
- A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.
- Word catheters may be ordered from Milex Products, Inc., Chicago, 11 (phone: 1-800-621-1278; http://www.milexproducts.com) or from your local Milex dealer.
Bibliography
1
Andersen PG, Christensen S, Detlefsen GU, et al. Treatment of Bartholin 's abscess: marsupialization versus incision, curettage and suture under antibiotic cover: a randomized study with 6 months ' follow-up.
Acta Obstet Gynecol Scand
. 1992;71:59 " 62. [View Abstract]
2
Bleker OP, Smalbraak DJ, Schutte ME. Bartholin 's abscess: the role of Chlamydia trachomatis.
Genitourin Med
. 1990;66:24 " 25. [View Abstract]
3
Brook I. Aerobic and anaerobic microbiology of Bartholin 's abscess.
Surg Gynecol Obstet.
1989;169:32 " 34. [View Abstract]
4
Curtis JM. Marsupialisation technique for Bartholin 's cyst.
Aust Farre Physician.
1993;22:369. [View Abstract]
5
Davies JA, Rees E, Hobson D, et al. Isolation of Chlamydia trachomatis from Bartholin 's ducts.
Br J Vener Dis
. 1978;54:409 " 413. [View Abstract]
6
Downs MC, Randall HW. The ambulatory surgical management of Bartholin duct cysts.
J Emerg Med
. 1989;7:623 " 626. [View Abstract]
7
Hill DA, Lense JJ. Office management of Bartholin gland cysts and abscesses.
Am Earn Physician
. 1998;57:1611 " 1616. [View Abstract]
8
Lee YH, Rankin JS, Alpert S, et al. Microbiological investigation of Bartholin 's gland abscesses and cysts.
Am J Obstet Gynecol.
1977;129:150 " 153. [View Abstract]
9
Monaghan JC. Fistulization for Bartholin 's gland cysts.
Patient Care
. 1991;5:119 " 122. 10
Omole F, Simmons BJ, Hacker Y. Management of Bartholin 's duct cyst and gland abscess.
Am Fam Physician.
2003;68:135 " 140. [View Abstract]
11
Wren MW. Bacteriological findings in cultures of clinical material from Bartholin 's abscess.
J Clin Pathol
. 1977;30:1025 " 1027. [View Abstract]
12
Yavetz H, Lessing JB, Jaffa AJ, et al. Fistulization: an effective treatment for Bartholin 's abscesses and cysts.
Acta Obstet Gynecol Scand
. 1987;66:63 " 64. [View Abstract]
13
2008 MAG Mutual Healthcare Solutions, Inc. 's
Physicians ' Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.
2007.