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

[Outline]

• DESCRIPTION
• EPIDEMIOLOGY
• ETIOLOGY

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

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

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

[Outline]

• ED TREATMENT/PROCEDURES
• MEDICATION

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.

FOLLOW-UP RECOMMENDATIONS

Continue sitz baths for at least 72 hr.

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• 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.

ICD9

• 098.0 Gonococcal infection (acute) of lower genitourinary tract
• 616.3 Abscess of Bartholin's gland

ICD10

• A54.02 Gonococcal vulvovaginitis, unspecified
• N75.1 Abscess of Bartholin's gland

[Outline]

• ICD9
• ICD10

• Bhide A, Nama V, Patel S, et al. Microbiology of cysts/abscesses of Bartholin's 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

Marilyn Althoff

Mark Mandell