Bartholin gland cyst and abscess

The Bartholin glands are located on both sides of the inner labia and primarily function to produce mucus that moisturizes the vaginal mucosa. The mucus is secreted into two ducts that appear in the posterior vaginal introitus. A Bartholin gland cyst is usually caused by blockage of the duct as a result of inflammation or trauma; a Bartholin gland abscess occurs when the obstructed duct becomes infected. The most common symptoms are swelling and, in the case that an abscess develops, pain and potentially fever. Both Bartholin gland cysts and abscess are clinical diagnoses. First-line treatment includes sitz baths, which may promote spontaneous rupture or resolution of the cyst after a few days. An abscess usually requires incision and must be drained surgically.

• ∼ 2% of women are affected at some point in their lives by a Bartholin gland cyst or abscess.
• Peak incidence: women in the reproductive age group

References:^[1][2]

Epidemiological data refers to the US, unless otherwise specified.

• Pathophysiology: : blockage of the duct by inflammation or trauma → accumulation of secretions from gland → cyst formation
• Clinical features: often asymptomatic but can cause mild dyspareunia
• Diagnostics
  • Pelvic exam: unilateral, palpable mass in the posterior vaginal introitus
  • Biopsy is indicated if any of the following apply:
    • > 40 years of age
    • Progressive, solid, and painless mass found during pelvic exam
    • Not responsive to treatment
    • History of malignancy in the labia
• Management ^[1][2]
  • Conservative approach
    • Indicated for smaller, asymptomatic cysts ≤ 3 cm
    • Involves sitz baths to facilitate rupture of the cyst; and/or warm compresses
  • Surgery
    • Indicated for larger cysts > 3 cm and/or infected cysts
    • See “Treatment” of Bartholin gland abscesses below.

A Bartholin gland cyst is generally a clinical diagnosis based on physical examination.

• Pathophysiology: polymicrobial infection e.g., E. coli (most common),; Staphylococcus species, Streptococcus species,N. gonorrhoeae, C. trachomatis; → infection of Bartholin gland or cyst
• Clinical features
  • Acute unilateral pain and tender swelling
  • Dyspareunia
  • Pain especially while walking and sitting
  • Fever (∼ 20% of cases)
  • Prompt pain relief with discharge (indicates spontaneous rupture of abscess)
• Diagnosis
  • Pelvic exam: unilateral, tender mass surrounded by edema and erythema in the posterior vaginal introitus
  • Possible culture
  • STD testing at the request of the patient .
  • Consider biopsy to rule out malignancy (see “Diagnostics” of Bartholin gland cyst above)
• Treatment
  • Surgery ^[1][2]
    • Indicated in all cases of abscess formation and large cysts (> 3 cm)
    • Involves incision and drainage followed by marsupialization or fistulization with a Word catheter
      • Incise the vestibule longitudinally to expose the cyst or abscess.
      • Drain cyst or abscess.
    • Marsupialization: indicated for recurring abscesses
      • Evert and suture the edges of the cyst wall to the cut edges of the vestibule.
      • This creates a new opening that allows free drainage
    • Fistulization with a Word catheter
      • A catheter is placed in the abscess cavity and left for four weeks
      • Facilitates drainage and allows for reepithelialization
      • Small abscesses (i.e., < 3 cm) may not be able to undergo catheterization, instead requiring supportive therapy (e.g., Sitz baths, warm compresses)
    • Biopsy: if malignancy is suspected
    • Gland excision: if malignancy is suspected or if previous measures are unsuccessful
  • Antibiotic therapy ^[3][4]
    • Indications
      • Recurrent abscesses (i.e., ≥ 2 episodes)
      • Risk of complicated infection (e.g., presence of cellulitis, pregnancy, immunocompromised state)
      • MRSA infection or risk factors for MRSA infection
      • Signs of systemic infection
      • Unsuccessful incision and drainage
    • Empiric oral antibiotic therapy covering Staphylococcus species, Streptococcus species, and enteric gram-negative aerobes is recommended and should be adjusted according to blood culture results.

• Bartholin gland carcinoma
  • Epidemiology: primarily found in postmenopausal women
  • Symptoms: gradual, solid, and painless enlargement of the Bartholin gland
  • Diagnostics: biopsy
  • Treatment
    • Resection of the lesion
    • If surgery is not possible or as adjuvant therapy: chemotherapy and radiation
• Folliculitis
• Inclusion cysts
• Leiomyomas
• Fibroma

References:^[5][6]

The differential diagnoses listed here are not exhaustive.