Author:
Steven P.Gohsler
Description
- The Bartholin gland s are located inferiorly on either side of vaginal opening at the 4 and 8 o'clock positions
- These gland s play an important role in the female reproductive system
- Main function is to secrete mucus and provide lubrication
- Ducts open on sides of labial vestibule
- Obstruction of duct usually produces a cyst presenting as a painless lump:
- Infection of these cysts result in abscess formation
Epidemiology
Prevalence
Most common in women aged 20-30 yr of age
Etiology
- Polymicrobial including anaerobic and aerobic microflora normally found in vagina:
- Escherichia coli - most common
- Bacteroides species
- Staphylococcus aureus
- Group B strep
- Enterococcus species
- Occasionally Neisseria gonorrhoeae and Chlamydia trachomatis
Risk Factors
- Previous history of Bartholin cyst
- Multiple sexual partners
- Sexually transmitted infection
- Vulva trauma
Signs and Symptoms
- Swollen, painful labia
- Tender, fluctuant mass on posterolateral margin of vestibule of vagina
History
Acute onset:
- Painful, unilateral labial swelling
- Pain with sitting, walking and limitation of physical activity
- Dyspareunia
Physical Exam
- Bartholin abscess:
- Tender, fluctuant, unilateral labial mass
- Vulva asymmetry
- Vaginal discharge
- Cellulitis may be present with surrounding erythema and edema
- Fever is uncommon
- Bartholin cyst:
- Painless, unilateral labial mass
Essential Workup
Diagnosis based on findings of tender, localized, fluctuant mass in region of Bartholin gland
Diagnostic Tests & Interpretation
Lab
- Routine culture of material from abscess to include testing for gonorrhea and chlamydia
- Culture cervix for gonorrhea and chlamydia
Imaging
Generally not indicated, although ultrasound may provide confirmatory evidence
Differential Diagnosis
- Bartholin cyst
- Different types of cysts: Inclusion, Gartner, Skene, and vestibular mucosa
- Carcinoma of Bartholin gland (rare)
- Hernias
ED Treatment/Procedures
- Primary treatment is surgical drainage with adjunctive antibiotics as necessary
- Alternative approaches include:
- Simple incision and drainage
- Word catheter method
- Marsupialization
- Simple incision and drainage:
- Place the patient in the lithotomy position
- Consider parenteral sedation, analgesia, or procedural sedation prior to local infiltration
- After local anesthesia, palpate abscess between thumb and index fingers
- Spread vulva apart and make a 1-cm vertical incision on mucosal surface of abscess, parallel to hymenal ring
- Extend the incision into the abscess cavity
- Free flow of purulent material indicates penetration of abscess wall
- Pack wound with gauze wick
- 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: First described by Dr. Buford Word in 1964
- The catheter is 5 cm and made of latex with a 10-Fr tip
- The tip contains a 5-mL balloon
- May avoid recurrence and make marsupialization unnecessary
- Patient preparation is similar to the incision and drainage technique
- Stab wound is made on the mucosal surface of the vestibule into the abscess cavity:
- 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 or saline
- Over inflation may cause patient discomfort
- Remedied by withdrawing some volume from balloon
- Sitz baths may be started after 24 hr
- Follow-up in 2-4 d
- 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
- Many gynecologists prefer to perform in the operating room
- Excise an ellipse of vestibular mucosa that overlays cyst/abscess cavity
- Insert a retractor to pull the mucosa open and visualize the wall of the sac
- Evert edges of cyst/abscess and suture them to mucosa of the vaginal vestibule 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 routinely prescribed after incision and drainage:
- If cellulitis is present or patient is otherwise immunocompromised, broad-spectrum coverage may be started
- If sexually transmitted disease (STD) suspected, treat with appropriate antibiotics
Medication
First Line
Broad-spectrum coverage:
Second Line
Treat for STD if indicated
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 d after insertion of Word catheter
Follow-up Recommendations
Continue sitz baths for at least 72 hr
- AnozieOB, EsikeCUO, AnozieRO, et al. Incidence, presentation and management of Bartholin's gland cysts/abscesses: A four year review in federal teaching hospital, Abakaliki, South-East Nigeria . OJOG. 2016;6:299-305.
- KessousR, Aricha-TamirB, SheizafB, et al. Clinical and microbiological characteristics of Bartholin's gland abscesses . Obstet Gynecol. 2013;122:794-799.
- KrissiH, ShmuelyA, AviramA, et al. Acute Bartholin's abscess: microbial spectrum, patient characteristics, clinical manifestations, and surgical outcomes . Eur J Clin Microbiol Infect Dis. 2016;35:443-446.
- KroeseJA, vand er VeldeM, MorssinkLP, et al. Word catheter and marsupialization in women with cyst or abscess of the Bartholin gland : Rand omized clinical trial . BJOG. 2017;124:243-249.
- LeeMY, DalpiazA, SchwambR, et al. Clinical pathology of Bartholin's gland : a review of the literature . Curr Urol. 2015;8:22-25.
- WordB. Office treatment of cyst and abscess of Bartholin's gland duct . South Med J. 1968;61:514-518.
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