The Bartholin glands are located in the labia minora at 4 o’clock and 8 o’clock, lateral to the bulbocavernosus muscle. The glands are connected to ducts that lie between the labia minora and the hymenal edge. They are nonpalpable, approximately 0.5 cm in diameter, and are used for lubrication and moisturizing the vaginal vestibular mucosa.

• Patients with Bartholin gland cysts may have a painless, unilateral, medial-protruding vulvar swelling mass without signs of surrounding cellulitis (Fig. E1).
• Patients with infected cyst or abscess may present after having a painless cyst, but then new onset of symptoms will occur, including but not limited to:
  1. Painful, acute swelling of unilateral labia; tender, fluctuant labial mass (Fig. E2); erythema; edema; dyspareunia; lymphangitis; pain while sitting or walking; or sudden discharge from abscess resulting in relief of pain.
  2. Fever is rare but may be present in individuals who are immunocompromised.
  3. The provider will be able to visualize unilateral swelling of labia and palpate a fluctuant mass at the inferior labia majora or lower vestibule. Purulent discharge may be noted if the abscess is rupturing. Patients may present complaining of drainage of an abscess that has already ruptured, but if completely drained, there may be no observation of a mass.
• Patients with vulvar carcinoma may also present with swelling of the Bartholin gland in up to 5% of cases.
  1. Presenting symptoms of malignant lesions of the Bartholin gland include painless mass, bleeding, and pruritus, but rarely pain.
  2. Missed diagnosis of malignancy may result in poorer outcome for those patients due to the extensive vascular and lymphatic vessels present in the vulva.
  3. Drainage of cyst and biopsy of cyst wall site are generally adequate for excluding malignancy.

• Cyst formation in the glands commonly results from mucus buildup in gland ducts.
• For abscesses, the most common pathogens are Escherichia coli and Staphylococcus aureus. Less common causative pathogens include Streptococcus pneumoniae and Haemophilus influenzae. The cause of a Bartholin abscess is rarely a sexually transmitted infection such as gonorrhea or chlamydia.

• Bartholin gland cyst or abscess
• Bartholin gland malignancy/vulvar malignancy
• Hidradenitis suppurativa
• Folliculitis
• Vaginitis
• Infectious causes: Genital warts, herpes simplex virus, syphilis/chancroid
• Less common considerations:
• Other types of cysts
  1. Cyst of canal of Nuck
  2. Epidermal inclusion cyst
  3. Gartner duct cyst
  4. Mucous cyst of the vestibule
  5. Skene duct cyst
  6. Sebaceous cyst
  7. Vestibular mucus cyst
• Endometriosis
• Hernia
• Hidradenoma
• Leiomyoma
• Lipoma
• Neurofibroma
• Syringoma
• Trauma/hematoma
• 10.Urethral diverticula

• Physical exam: Determine size and presence or absence of fluctuance. Assess for local signs of infection. Assess for systemic symptoms such as fever and lymphadenopathy.
• Sexually transmitted infection testing if indicated
• Biopsy or excision in women over age 40, or with history of vulvar carcinoma

• Can consider culture if drainage is performed. Abscess cultures most often show polymicrobial infection.
• The most common indication for culture would be the presence of concomitant cellulitis.

• Often not necessary to obtain imaging. Asymptomatic cysts may be found incidentally on MRI, CT, or high-definition ultrasound.
  1. In one study, approximately 3% of asymptomatic women had Bartholin gland cysts visualized on MRI.

1. No treatment: Patient is asymptomatic or cyst is not interfering with activities of daily living. Many tend to rupture spontaneously.
2. Sitz baths: Recommended following spontaneous rupture. Utilize three times per day to promote spontaneous rupture of the cyst. Can use a warm, shallow bath or warm compress in place of sitz bath. Avoid perfumed soaps or bath salts.

Healing and recurrence rates are similar among fistulization, marsupialization, silver nitrate, and alcohol sclerotherapy. Needle aspiration and incision and drainage are the two simplest procedures but are not recommended due to increased recurrence rate.

1. Simple needle aspiration: Making a small incision with a needle insertion into the cyst to facilitate drainage. This technique has a high rate for recurrence and thus is not recommended.
2. Incision and drainage (I&D): Incision and drainage can be accomplished via a variety of techniques to promote facilitation of drainage and relief of pain from fluid collection. Of note, do not perform this procedure if you are not able to detect fluctuance suspicious for localized fluid collection on exam.
   1. Local anesthesia is essential when draining abscesses to promote patient tolerance and comfort with procedure. It is important to apply anesthesia to the tissue mucosa instead of the abscess. Anesthesia directed at the fluid collection will not provide proper pain relief for procedure.
   2. Performed in office or outpatient setting.
   3. Procedure: Following local anesthetic injection, a small 2- to 5-mm incision is made with #11 surgical blade into abscess internal to the hymenal ring if possible. The contents are then manually expressed to promote drainage. Loculations can be broken up with a sterile Q-tip. Next, the area is flushed with sterile saline. The incisional site can then be packed with packing or left alone. If packing is placed, it should be removed 2 days after procedure.
   4. This technique provides immediate relief of discomfort but comes with high risk of recurrence.
3. Fistulization: Creation of a new outflow tract by placing a drainage catheter, such as a Word catheter or Jacobi Ring, into the incision following I&D. See procedure for I&D.
   1. Instead of gauze packing, a catheter is inserted into the abscess to promote continual drainage and to facilitate outflow tract development.
   2. Procedure: After incision is cleansed with sterile saline, the catheter is inserted. The bulb is inflated with 3 to 5 cc of saline. The catheter is then tucked in vagina and suture may be used to close the incision and to help keep the catheter in place. In one study, a Word catheter as treatment was successful in 26 of 30 cases (87%) of Bartholin cyst or abscess (Fig. E3). Of note, it is common for catheters to fall out, and patients should be counseled regarding this possibility.
   3. The catheter is left inside for up to 4 wk to ensure epithelialization, and sitz baths are also recommended during this time.
   4. Catheter treatment is not advised for treatment of deep cysts/abscesses.
4. Marsupialization: This management option is for primary or recurrent cysts that have failed fistulization. This surgical procedure is usually performed in outpatient surgical site when abscess is not present.
   1. Procedure: Overlying surface of cyst is cleaned with Betadine. Small hemostats are used to grasp the cyst and a vertical incision 1.5 to 3 cm is made with #11 or #15 blade to drain the gland cavity. Saline solution can be used to flush the cavity. Cyst walls are then everted and held in place by interrupted absorbable suture, 2-0 or 3-0 Vicryl.
   2. This treatment should not be used if abscess is suspected.
   3. Sitz baths are recommended at least daily following procedure.
   4. Complications: Infection, hematoma, or dyspareunia. Heals in approximately 2 wk following surgery.
5. Surgical excision: Reserved for recurrent cysts or suspicion of malignancy. This surgical procedure is rarely needed for treatment of uncomplicated abscesses.
6. Other treatment options
7. CO₂ laser
   1. Used to incise the cyst and vaporize the wall from inside.
8. Silver nitrate sclerotherapy
   1. A clamp is placed on cyst/abscess and contents are drained. A 5-mm diameter silver nitrate stick is trimmed to 5 mm in length and inserted into the cavity. A single suture is applied to the incision site to keep the stick in the cavity while allowing for continued drainage. Three days later, the nitrate stick is removed along with the necrotized tissue using a clamp.
9. Alcohol sclerotherapy
   1. 18- to 20-gauge needle is inserted into the cyst at the point of maximal fluctuation and contents are aspirated until cyst walls collapse. A similar volume of 70% alcohol is injected into the cyst, left for 5 minutes, and then reaspirated.

• Analgesia for significant Bartholin abscess pain.
  1. Topical anesthetics such as lidocaine or bupivacaine should be utilized, especially during drainage. Again, anesthetic should be applied to surrounding mucosa, as direct application into cyst will lead to inadequate anesthesia.
  2. Following drainage and treatment, the patient will experience immediate relief, although they may still require oral analgesia for a few days following the procedure.
• Antibiotics are not necessary for uncomplicated abscesses.
  1. Indications for antibiotics include recurrence, pregnancy, immunosuppression, methicillin-resistant Staphylococcus aureus, widespread surrounding cellulitis, concurrent UTI, or concurrent gonorrhea or chlamydia infection.
  2. Common antibiotics when needed include trimethoprim-sulfamethoxazole, amoxicillin-clavulanate, or second-generation cephalosporins. When choosing an antibiotic, be sure to reference your institution’s antibiogram.
  3. Consider culturing the abscess if there is surrounding cellulitis or the abscess returns despite initial antibiotic therapy. It is acceptable to start or continue broad-spectrum antibiotics while waiting for cultures to return.
• For malignancy of the Bartholin gland, treatment regimens are similar to those used for vulvar carcinoma. Full coverage of this topic is outside the scope of this chapter.

• Admission is not necessary unless systemic infection/sepsis is suspected.

• If malignancy is suspected, referral to gynecologic oncology is recommended.

Vaginal Fistulas (Related Key Topic)

Hidradenitis Suppurativa (Related Key Topic)