Basics
Description
- The Bartholin glands are located inferiorly on either side of vaginal opening:
- Ducts open on sides of labial vestibule.
- Obstruction of duct produces a usually painless cyst:
- Infection of cyst results in abscess formation.
Epidemiology
Prevalence
Most common in women aged 20-40 yr
Etiology
- Anaerobic and aerobic microflora normally found in vagina:
- Bacteroides species
- Peptostreptococcus species
- Escherichia coli
- Other gram-negative organisms
- Occasionally Neisseria gonorrhoeae and Chlamydia trachomatis
Diagnosis
Signs and Symptoms
- Swollen, painful labia
- Tender, fluctuant mass on posterolateral margin of vestibule of vagina
- Warmth, erythema
History
Acute onset:
- Painful, unilateral labial swelling
- Pain with sitting, walking
- Dyspareunia
Physical Exam
- Bartholin abscess:
- Tender, fluctuant, unilateral labial mass
- Surrounding erythema, warmth
- Fever uncommon
- Bartholin cyst:
- Painless, unilateral labial mass
Essential Workup
Diagnosis based on findings of tender, localized, fluctuant mass in region of Bartholin gland
Diagnosis Tests & Interpretation
Lab
- Culture material from abscess for gonorrhea and chlamydia.
- Culture cervix for gonorrhea and chlamydia.
Imaging
Generally not indicated
Differential Diagnosis
- Bartholin cyst
- Carcinoma of Bartholin gland (rare)
- Perineal hernia
Treatment
Ed Treatment/Procedures
- Prompt incision and drainage using local anesthesia with patient in lithotomy position
- Narcotic analgesia for patient comfort
- Alternative approaches include:
- Simple incision and drainage
- Word catheter method
- Marsupialization
- Simple incision and drainage:
- After local anesthesia, palpate abscess between thumb and index fingers.
- Spread vulva apart and make stab incision on mucosal surface of abscess, parallel to hymenal ring.
- When incising abscess, 2 tissue layers must be penetrated:
- 1st the labial mucosa
- Then abscess wall
- Free flow of pus indicates penetration of abscess wall.
- Pack wound with gauze.
- Follow-up in 24-48 hr for removal of packing.
- Start sitz baths after 24 hr.
- Consider referral for marsupialization to avoid recurrence.
- Word catheter method:
- Use small, inflatable, bulb-tipped Word catheter to treat abscess.
- May avoid recurrence and make marsupialization unnecessary
- Stab wound is made as with simple incision and drainage:
- It should be just large enough to easily admit catheter so that balloon does not fall out after inflation.
- After inserting bulb tip of catheter, inflate balloon by injecting 2-4 mL water using 25G needle (to minimize size of puncture):
- Overinflation may cause patient discomfort
- Remedied by withdrawing some water from balloon
- Sitz baths may be started after 24 hr.
- Follow-up in 2-4 days.
- Leave catheter in place for 6-8 wk until epithelialization is complete; after device is removed, gland resumes normal function.
- Common for catheter to fall out prematurely:
- If this occurs, catheter may be reinserted or abscess can heal as with simple incision and drainage.
- Marsupialization:
- Procedure allows for a permanent fistula by suturing wound edges of abscess cavity to edges of labial mucosa:
- Technically more challenging in ED and better reserved for specialist.
- Excise an ellipse of labial mucosa that overlays cyst cavity.
- Incision and drainage of abscess
- Evert edges of abscess and suture them to labial epithelium using absorbable suture:
- Opening will shrink but remain patent.
- Packing is not needed.
- Start sitz baths in 24-48 hr.
- Follow-up within 1 wk.
- Antibiotics not necessary after incision and drainage:
- If mild cellulitis present or patient immunocompromised, broad-spectrum coverage may be started.
- If sexually transmitted disease (STD) suspected, treat with antibiotics.
Medication
First Line
Broad-spectrum coverage:
- Amoxicillin/clavulanic acid: 500-875 mg PO BID for 5 days with metronidazole 500 mg PO q8h for 5 days
- Ciprofloxacin: 500 mg PO BID for 5 days with metronidazole 500 mg PO q8h for 5 days
Second Line
Treat for STD if indicated
Follow-Up
Disposition
Admission Criteria
- Sepsis
- Significant cellulitis
- Evidence of necrotizing infection
Discharge Criteria
Well-appearing patients may be discharged with designated follow-up plan.
Issues for Referral
Patients should have gynecologic follow-up:
- Follow-up in 24-48 hr for removal of packing.
- Follow-up in 2-4 days after insertion of Word catheter.
Followup Recommendations
Continue sitz baths for at least 72 hr.
Pearls and Pitfalls
- Do not mistake a nontender Bartholin cyst, which does not require immediate treatment, for an inflamed abscess.
- Consider malignancy as an alternative cause of a mass, particularly in women >40 yr.
- Incision should be on mucosal surface of abscess.
Additional Reading
- Bhide A, Nama V, Patel S, et al. Microbiology of cysts/abscesses of Bartholins gland: Review of empirical antibiotic therapy against microbial culture. J Obstet Gynaecol. 2010;30:701-703.
- Patil S, Sultan AH, Thakar R. Bartholin's cysts and abscesses. J Obstet Gynaecol. 2007;27:241-245.
- Pundir J, Auld BJ. A review of the management of diseases of Bartholin's gland. J Obstet Gynaecol. 2008;28:161-165.
- Word B. Office treatment of cyst and abscess of Bartholin's gland duct. South Med J. 1968;61:514-518.
See Also (Topic, Algorithm, Electronic Media Element)
- Treatment of Chlamydia
- Treatment of Gonococcal Disease
Codes
ICD9
- 098.0 Gonococcal infection (acute) of lower genitourinary tract
- 616.3 Abscess of Bartholins gland
ICD10
- A54.02 Gonococcal vulvovaginitis, unspecified
- N75.1 Abscess of Bartholins gland
SNOMED
- 67624004 abscess of Bartholins gland (disorder)
- 240573005 Gonococcal Bartholin's gland abscess (disorder)