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Bartholin’s Cyst

Basics

Description

- 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

- 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.

- 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

- 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

  • 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. пїЅ

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 speciesMethicillin-resistant Staphylococcus aureus possible but rareAnaerobes: Bacteroides species, Peptostreptococcus species
  • STD possible, but less common: Neisseria gonorrhoeae, Chlamydia trachomatis (1)[B]

Associated Conditions

STD: N. gonorrhoeae, C. trachomatis (rare) пїЅ

Diagnosis

History

  • Age
  • Prior history of Bartholin's cyst or abscess
  • Vaginal discharge
  • Prior history of STD
  • CystAsymptomatic or may have vulvar discomfortDiscomfort aggravated by sitting, walking, and sexual intercourse
  • AbscessPainful vulvar massRapid growthPain aggravated by sitting, walking, and sexual intercourseFever

Physical Exam

  • CystSoft, painless, unilateral labial mass
  • AbscessVery tender, warm, fluctuant unilateral labial massEdema and erythema may be present.May have surrounding cellulitisMay have feverIf 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 пїЅ

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 infectionCefixime 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. пїЅ

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 pointSpontaneous 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] пїЅ

  • Incision and drainage aloneNot recommended due to high recurrence
  • Word catheter (inflatable bulb-tipped catheter) placementPut 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.
  • Marsupialization1.5-2 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 пїЅ

Several methods described in the literature but none with widespread use пїЅ

  • Silver nitrateAfter 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 vaporizationIncision and drainage followed by vaporization to create a new drainage pathway or destroy the cyst lining.Little scaring but expensive
  • Alcohol sclerotherapyIncision and drainage followed by irrigation with 70% alcohol for 5 minutes and evacuationMain disadvantages are tissue necrosis and scar formation.

Day surgery пїЅ

  • Excision of the gland (when no active infection)If conservative therapy repeatedly failsIf suspect Bartholin's gland carcinomaOften 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 пїЅ

Prognosis

  • Healing times vary depending on procedure. Usually heal within 2-4 weeks.
  • Recurrence ratesIncision 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 пїЅJ, Auld пїЅBJ A review of the management of diseases of the Bartholin's gland. J Obstet Gynecol. 2008;28(2):161-165.2Marzano пїЅDA, Haefner пїЅHK The Bartholin gland cyst: Past, present, and future. J Low Genit Tract Dis. 2004;8(3):195-204.3Wechter пїЅME, Wu пїЅJM, Marzano пїЅD Management of Bartholin duct cysts and abscesses. Obstet Gynecol Surv. 2009;64(6):395-404.

Additional Reading

1Fambrini пїЅM, Penna пїЅC, Pieralli пїЅA 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 пїЅO, Kayikcioglu пїЅF, Haberal пїЅA. 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.