Bartholin's Gland Abscess

Aka: Bartholin's Gland Abscess, Bartholin Gland Abscess, Bartholin's Abscess, Bartholin's Gland Duct Cyst, Bartholin's Gland Cyst, Bartholin Duct Cyst, Bartholin Cyst, Bartholin Gland, Word Catheter, Bartholin Gland Catheter, Jacobi Ring

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II. Epidemiology

  1. Bartholin's Gland Duct Cysts and abscess Incidence: 2%
  2. Most common in adult women under age 30 years

III. Pathophysiology

  1. Bartholin's Gland
    1. Homologues to male bulbourethral glands
    2. Vaginal vestibular glands provide moisture during arousal and intercourse
      1. Moisture is also provided by Skene glands
    3. Located at bilateral inferior labia minora
    4. Drain via 2 to 2.5 cm long ducts at 4:00 and 8:00 positions of labia
    5. Normal Bartholin's gland size <1 cm and not typically palpable
    6. Glands are lined by columnar epithelium, while ducts are lined by squamous epithelium
    7. Typically Bartholin Glands involute around 30 years old
  2. Bartholin's Gland Duct Cyst
    1. Results from distal duct obstruction, often from friction with intercourse
  3. Bartholin's Gland Abscess (more common than cysts)
    1. May occur spontaneously or as infection of duct cyst

IV. Causes: Bacterial (Abscess)

  1. Most common organisms
    1. Escherichia coli
    2. Staphylococcus aureus
  2. Other common causes (increasing Incidence, may be related to oral sex)
    1. Streptococcus Pneumoniae
    2. HaemophilusInfluenzae
  3. Sexually Transmitted Disease may also cause abscesses in the United States
    1. Chlamydia trachomatis
    2. Neisseria gonorrhoeae
  4. Other causes
    1. Streptococcus faecalis
    2. Pseudomonas aeruginosa
    3. Bacteroides fragilis
    4. Clostridium perfringens

V. Precautions

  1. Consider malignancy for Bartholin Gland cyst or abscess at age >40 years old

VI. Symptoms

  1. Vulvar Pain worse with walking and intercourse
  2. Fever may be present with abscess

VII. Signs

  1. Unilateral, firm swelling at posterior vaginal introitus
    1. Occurs at 5:00 and 7:00 positions (where Bartholin Gland ducts exit)
    2. Posterior labia minora affected

VIII. Labs

  1. Consider screening for Sexually Transmitted Disease (see causes above)
  2. Consider biopsy in women over age 40 years old

IX. Differential Diagnosis

  1. Cystic lesions
    1. Epidermal Inclusion Cyst (at labia majora)
    2. Skene's Duct cyst (at Urethral meatus)
    3. Cyst at Canal of Nuck (at labia majora, mons pubis)
      1. Hydrocele protruding through inguinal ring into the labia majora
      2. May also be associated with an Inguinal Hernia
      3. Presents as a translucent cyst in the labia, worse with standing and better supine
    4. Gartner Duct Cyst
      1. Wolfian duct (mesonephric duct) remnant results in vaginal inclusion cyst to either side of Urethra
    5. Hidradenoma papilliferum (between labia majora and labia minora)
    6. Mucous cyst of vestibule
  2. Solid lesions
    1. Cancerous growths
      1. More common over age 40 years old (esp. postmenopausal woman)
      2. Accounts for 5% of vulvar carcinomas
      3. Early detection prevents local invasion and metastases
      4. Types
        1. Squamous Cell Carcinoma of the Bartholin duct (associated with HPV 16)
        2. Adenocarcinoma of the Bartholin Gland
    2. Benign growths
      1. Acrochordon
        1. At labia majora
        2. Fleshy, polypoid, often pedunculated lesion
      2. Angiokeratoma
        1. Benign, rare, vascular lesions (esp. in pregnancy, Fabry Disease)
      3. Fibroma
        1. At labia majora, introitus, perineal body
        2. Firm swelling and typically asymptomatic
      4. Lipoma
        1. At Labia majora, clitoris
        2. May be pedunculated
      5. Leiomyoma
        1. At labia majora
        2. Rare, firm outgrowth from Smooth Muscle
      6. Neurofibroma
        1. Small, fleshy, polypoid lesion
        2. Associated with von Recklinghausen Disease

X. Management: Approach

  1. Asymptomatic Bartholin Gland cyst (and no abscess)
    1. Age <40 years: No treatment required
    2. Age >40 years: Biopsy
  2. Antibiotic indications
    1. Cellulitis with abscess
    2. Sexually Transmitted Infection
    3. Urinary Tract Infection
  3. Acute abscess or symptomatic cyst: Fistulization (create a new outflow tract, using techniques below)
    1. Word Catheter
    2. Jacobi Ring
  4. Recurrent Bartholin Cyst
    1. Marsupialization of Bartholin's Gland Cysts
    2. Alcohol Sclerotherapy
  5. Refractory Bartholin Cyst or age over 40 years old (cancer risk)
    1. Excision of of Bartholin's Gland Cyst
  6. Avoid low efficacy procedures with high recurrence rates
    1. Simple Incision and Drainage (without fistulization or marsupilization)
    2. Cyst needle aspiration (without sclerotherapy)

XI. Management: Word Catheter Placement for cyst or abscess (fistulization)

  1. Betadine prep or Hibiclens overlying abscess wall at labia
  2. Administer Local Anesthesia with Lidocaine 1%
  3. Make 5 mm stab incision over abscess with #11 blade
    1. Incision should be oriented vertically
    2. Incision should lie outside hymenal ring
  4. Insert Word Catheter into incision
    1. Inflate Word Catheter balloon with 2-3 cc saline
  5. Word Catheter remains in place for 4-6 weeks minimum
    1. Up to 3 months are required in some cases for adequate recanalization
    2. Balloon often spontaneously self-expels (consider suturing incision to hold in place)
  6. Video of technique
    1. https://www.youtube.com/watch?v=zyopxjyExtI

XII. Management: Jacobi Ring

  1. Preparation
    1. Catheter creation
      1. T Tube 8 french, cut a 7 cm length
      2. Butterfly catheter tubing, cut a 5 cm length
    2. Thread the catheter
      1. Silk Suture 2-0, 20 cm length
  2. Betadine prep or Hibiclens overlying abscess wall at labia
  3. Administer Local Anesthesia with Lidocaine 1%
  4. Make 5 mm stab incision over abscess with #11 blade
    1. Incision should be oriented vertically
    2. Incision should lie outside hymenal ring
  5. Use a hemostat to break adhesions within abscess
  6. Tunnel hemostat to superior pole of the abscess and back through the mucosa
    1. Incise over the surface of the hemostat
    2. Grasp one end of Jacobi Ring and pull through the original incision
  7. Tie the Suture ends

XIII. Management: Other measures (typically by Gynecology)

  1. Marsupialization of Bartholin's Gland Cysts
    1. Only use for recurrent cysts (contraindicated for abscess)
    2. Incision overlies the entire length of the cyst wall
    3. Cyst wall excised, irrigated with saline
    4. Cyst wall and mucosa are Sutured open with Absorbable Suture (Vicryl 2-0, 3-0)
    5. Start Sitz baths on day 1 and perform daily
    6. Re-evaluate at 4 weeks
    7. Technique Video
      1. https://www.youtube.com/watch?v=mqNmGMv815E
  2. Alcohol Sclerotherapy
    1. Silver Nitrate sclerotherapy may be used instead (but has a longer healing time)
    2. Aspirate the cyst with an 18-20 gauge needle until cyst wall collapses
    3. With the needle in place, reinject 70% Alcohol back into the cyst (similar volume of aspirated fluid)
    4. After 5 minutes, aspirate Alcohol from the cyst
    5. Expect healing within 1 week
  3. Excision of of Bartholin's Gland Cyst
    1. Indicated if refractory to other measures or age 40 years or older (cancer risk)
    2. Procedure timed when no infection present
    3. Refer to Gynecology or Surgery for procedure

XIV. References

  1. Apgar in Pfenninger (1994) Procedures p. 596-600
  2. Omole (2003) Am Fam Physician 68(1):135-40 [PubMed]
  3. Omole (2019) Am Fam Physician 99(12): 760-66 [PubMed]

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