Basics
Description
- Bartholin's glands are also known as the greater vestibular glands.
- Bartholin's glands (0.5 cm size) are vulvovaginal glands located bilaterally at the base of the labia minora at the 4 o'clock and 8 o'clock positions and drain through 2.5 cm long ducts into the posterior lateral vestibule.
- They provide moisture for the vestibule but are not required for sexual lubrication.
- Occlusion of the duct opening can lead to cyst formation.
- Most cysts are small (1-3 cm) and asymptomatic. They can become symptomatic if large.
- Infection of a cyst can lead to abscess formation.
- Abscesses present with acute, rapidly progressive vulvar pain.
Epidemiology
- Most common in women 20-30 years of age
- Most common cause of vulvar cyst
Prevalence
2% of women of reproductive age develop a cyst or abscess. �
Risk Factors
- Prior history of cysts or abscesses
- Vaginal infections - sexually transmitted diseases (STDs)
- Vulvar trauma
General Prevention
- Not preventable
- Decrease risk of STD with condom use
Pathophysiology
- Inflammation (infection, trauma) may cause occlusion of the distal duct.
- Congenital narrowing of the duct and thick mucous may contribute to ductal obstruction.
- The obstruction results in retention of secretions leading to dilatation of the duct and formation of a cyst.
- Cyst can get infected, resulting in an abscess.
Etiology
- Infection is usually polymicrobial, often similar to vaginal flora (1)[B]
- Aerobes: Escherichia coli, Staphylococcus species, Streptococcus species
- Methicillin-resistant Staphylococcus aureus possible but rare
- Anaerobes: Bacteroides species, Peptostreptococcus species
- STD possible, but less common: Neisseria gonorrhoeae, Chlamydia trachomatis (1)[B]
Associated Conditions
STD: N. gonorrhoeae, C. trachomatis (rare) �
Diagnosis
History
- Age
- Prior history of Bartholin's cyst or abscess
- Vaginal discharge
- Prior history of STD
- Cyst
- Asymptomatic or may have vulvar discomfort
- Discomfort aggravated by sitting, walking, and sexual intercourse
- Abscess
- Painful vulvar mass
- Rapid growth
- Pain aggravated by sitting, walking, and sexual intercourse
- Fever
Physical Exam
- Cyst
- Soft, painless, unilateral labial mass
- Abscess
- Very tender, warm, fluctuant unilateral labial mass
- Edema and erythema may be present.
- May have surrounding cellulitis
- May have fever
- If the abscess has spontaneously ruptured, purulent discharge may be seen.
Tests
Lab
- Test for N. gonorrhoeae and C. trachomatis (cervical specimen or abscess fluid) if risk factors present (1)[B].
- Cyst/abscess fluid not routinely cultured for pathogens (1)[B].
- Blood tests are not usually needed; if patient is febrile or systemically ill, check CBC and blood cultures (1)[B].
Imaging
Not usually indicated �
Pathological Findings
- Cysts are usually sterile.
- Abscesses are often polymicrobial with both aerobes and anaerobes.
Differential Diagnosis
- Epidermal inclusion or sebaceous cyst (2)[B]
- Mucous cyst
- Gartner's duct cyst
- Skene's duct cyst
- Cyst of the canal of Nuck
- Fibroma
- Fibroadenoma
- Lipoma
- Leiomyoma
- Syringoma
- Papillary hidradenoma
- Inguinal hernia
- Hematoma
- Ischiorectal abscess
- Endometriosis
- Accessory breast tissue
- Bartholin's gland malignancy (rare)
Treatment
- Asymptomatic cyst
- <40 years old do not require therapy
- ≥40 years old require drainage and biopsy to rule out cancer
- Symptomatic cyst/abscess requires drainage.
- All solid nodules should be biopsied to rule out malignancy (1)[B].
Medication
- Pain control
- Broad-spectrum antibiotics indicated for cellulitis, immunosuppression, systemic signs of infection
- Cefixime 400 mg PO once daily (7 days) and clindamycin 300 mg PO 4 times per day (7 days)
- If tests are positive or strongly suspect gonorrhea, treat with cefixime 400 mg PO (1 dose) or ceftriaxone 125 mg IM (1 dose).
- If tests are positive or strongly suspect chlamydia, treat with azithromycin 1 g PO (1 dose) or doxycycline 100 mg PO twice daily (7 days).
Rarely sepsis and necrotizing infections may occur. �
Additional Treatment
General Measures
- Sitz baths (warm water soaks) or warm compresses 3/day for several days if:
- Small (<2 cm), early abscess to help the abscess form a point
- Spontaneous rupture of a cyst/abscess to provide relief and promote drainage
Issues for Referral
- Urgent gynecology referral for all abscesses for definitive treatment
- Gynecology referral for all solid nodules and all lesions in women ≥40 years old for biopsy
Surgery
- Indicated for all symptomatic lesions
- Establishing a drainage path is essential to prevent recurrence.
Biopsy all solid nodules and all lesions in women ≥40 years old. Office-based procedures (1)[B] (2)[B] (3)[B] �
- Incision and drainage alone
- Not recommended due to high recurrence
- Word catheter (inflatable bulb-tipped catheter) placement
- Put into the cyst/abscess after incision and drainage. The bulb is inflated and left in place for 4-6 weeks to allow formation of an epithelialized tract for drainage of glandular secretions.
- Easy to perform, main disadvantage is dislodging of catheter before an epithelialized track has formed.
- Marsupialization
- 1.5-2 cm incision into cyst/abscess. A common variation is to make an elliptical incision and remove 1-2 cm oval portion of the cyst wall.
- The cyst/abscess wall is everted and sewn with interrupted sutures to the vestibular mucosa.
- Easy to perform, main disadvantages are dyspareunia due to scarring and prolonged healing.
- Usually used after Word catheter has failed
Gland destruction �
Several methods described in the literature but none with widespread use �
- Silver nitrate
- After incision and drainage, a crystalloid silver nitrate stick is put into cyst/abscess. After 48 hours, necrotized tissue and remaining silver nitrate particles are removed.
- Main disadvantage is chemical burns of vulva.
- CO2 laser vaporization
- Incision and drainage followed by vaporization to create a new drainage pathway or destroy the cyst lining.
- Little scaring but expensive
- Alcohol sclerotherapy
- Incision and drainage followed by irrigation with 70% alcohol for 5 minutes and evacuation
- Main disadvantages are tissue necrosis and scar formation.
Day surgery �
- Excision of the gland (when no active infection)
- If conservative therapy repeatedly fails
- If suspect Bartholin's gland carcinoma
- Often a difficult procedure with high morbidity: Excessive bleeding, scarring, dyspareunia, disfigurement, prolonged healing time
Ongoing Care
Follow-Up Recommendations
- After Word catheter placement - sitz baths 3/day
- Will depend on procedure
Patient Monitoring
- Initial follow-up visit in 48 hours
- Will depend on procedure
Patient Education
Seek medical care immediately if develop worsening pain, erythema, swelling, or fever �
Prognosis
- Healing times vary depending on procedure. Usually heal within 2-4 weeks.
- Recurrence rates
- Incision and drainage: up to 38%
- Word catheter: 3-15%
- Marsupialization: 2-24%
- Silver nitrate: 4-26%
- CO2 laser: 2-20%
- Alcohol sclerotherapy: 8-10%
- Gland excision: <3%
Complications
- Hemorrhage and hematoma
- Infection
- Scarring
- Dyspareunia
References
1Pundir �J, Auld �BJ A review of the management of diseases of the Bartholin's gland. J Obstet Gynecol. 2008;28(2):161-165.2Marzano �DA, Haefner �HK The Bartholin gland cyst: Past, present, and future. J Low Genit Tract Dis. 2004;8(3):195-204.3Wechter �ME, Wu �JM, Marzano �D Management of Bartholin duct cysts and abscesses. Obstet Gynecol Surv. 2009;64(6):395-404.
Additional Reading
1Fambrini �M, Penna �C, Pieralli �A Carbon-dioxide laser vaporization of the Bartholin gland cyst: A retrospective analysis on 200 cases. J Minim Invasive Gynecol. 2008;15(3):327-331.2Ozdegirmenci �O, Kayikcioglu �F, Haberal �A. Prospective randomized study of marsupialization versus silver nitrate application in the management of Bartholin gland cysts and abscesses. J Minim Invasive Gynecol. 2009;16(2):149-152.
Codes
ICD9
- 616.2 Cyst of Bartholin's gland
- 616.3 Abscess of Bartholin's gland
ICD10
- N75.0 Cyst of Bartholin's gland
- N75.1 Abscess of Bartholin's gland
SNOMED
- 57044006 cyst of Bartholin's gland duct (disorder)
- 67624004 abscess of Bartholin's gland (disorder)
Clinical Pearls
- Common problem in women of reproductive age
- Symptomatic cyst/abscess usually requires surgical intervention.
- An abscess should be considered in a painful, rapidly growing vulvar mass.
- A vulvar mass in women ≥40 years old should be evaluated for malignancy.
- Biopsy all solid lesions to rule out malignancy.