Bartholin Abscess, Emergency Medicine

Basics

Description

- Anaerobic and aerobic microflora normally found in vagina: - Bacteroides species - Peptostreptococcus species - Escherichia coli - Other gram-negative organisms

- Bartholin abscess: - Tender, fluctuant, unilateral labial mass - Surrounding erythema, warmth - Fever uncommon

- 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

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 speciesPeptostreptococcus speciesEscherichia coliOther 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 massSurrounding erythema, warmthFever 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 drainageWord catheter methodMarsupialization
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 mucosaThen abscess wallFree 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 unnecessaryStab 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 discomfortRemedied by withdrawing some water from balloonSitz 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 abscessEvert 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.

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)