eMedicine Specialties > Emergency Medicine > Genitourinary

Bartholin Gland Diseases

Jennifer Coles Schecter, MD, Staff Physician, Department of Emergency Medicine, Lahey Clinic, Burlington, MA
Antonia Quinn, DO, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate Medical Center/Kings County Hospital Center; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Updated: Dec 2, 2009

Introduction

Background

Bartholin glands were first described by Caspar Bartholin, a Dutch anatomist, in 1677. These paired glands are approximately 0.5 cm in diameter and are found in the labia minora in the 4- and 8-o’clock positions. Typically, they are nonpalpable. Each gland secretes mucus into a 2.5 cm duct. These two ducts emerge onto the vestibule at either side of the vaginal orifice, inferior to the hymen. Their function is to maintain the moisture of the vaginal mucosa's vestibular surface.

This article focuses on the most common Bartholin gland diseases, cysts and abscesses. Although rare, carcinoma of the gland should be considered in women with an atypical presentation.

Pathophysiology

Bartholin glands are known to form cysts and abscesses in women of reproductive age. Cysts and abscesses are often clinically distinguishable. Bartholin cysts form when the ostium of the duct becomes obstructed, leading to distention of the gland or duct with fluid. Obstruction is usually secondary to nonspecific inflammation or trauma. The cyst is usually 1-3 cm in diameter and often asymptomatic, although larger cysts may be associated with pain and dyspareunia.

Bartholin abscesses result from either primary gland infection or infected cyst. Patients with abscesses complain of acute, rapidly progressive vulvar pain. Studies have shown that these abscesses are usually polymicrobial and rarely attributable to sexually transmitted pathogens.

Adenocarcinoma of the Bartholin glands is rare, accounting for 1-2% of all vulvar malignancies. Typically, this lesion presents as a gradually enlarging gland in an asymptomatic, postmenopausal woman.

Frequency

United States

Approximately 2% of women of reproductive age will experience swelling of one or both Bartholin glands.

Mortality/Morbidity

Bartholin gland diseases are rarely complicated by systemic infection, sepsis, and bleeding secondary to surgical treatment. Missed diagnosis of malignancy may result in poorer outcome for those patients.

Race

No difference exists in the frequency of Bartholin gland diseases among different races.

Sex

Bartholin glands are present only in females.

Age

These diseases typically occur in women between the ages of 20 and 30 years. Bartholin gland enlargement in patients older than 40 years is rare and should be referred to a gynecologist for possible biopsy.

Clinical

History

Patients with cysts may present with painless labial swelling. Abscesses may present spontaneously or after a painless cyst with the following symptoms:

• Acute, painful unilateral labial swelling
• Dyspareunia
• Pain with walking and sitting
• Sudden relief of pain followed by discharge (highly suggestive of spontaneous rupture)

Physical

The following physical examination findings are seen in Bartholin abscess, as shown in the image below.

Bartholin abscess.

• Patients typically have an exquisitely tender, fluctuant labial mass with surrounding erythema and edema.
• In some cases, areas of cellulitis surrounding the abscess may be present.
• Fever, though not typical in healthy patients, may occur.
• If the abscess has spontaneously ruptured, purulent discharge may be noted. If completely drained, no obvious mass may be observed.

The following physical examination findings are seen in Bartholin cysts:

• Patients may have a painless, unilateral labial mass without signs of surrounding cellulitis.
• If large, the cyst may be tender.
• Discharge from ruptured cyst should be nonpurulent.

Causes

Uncomplicated Bartholin cysts are filled with nonpurulent mucous. Several studies have aimed to identify the most common bacterial pathogens responsible for Bartholin abscess formation. Studies from the 1970-1980s named Neisseria gonorrhoeae and Chlamydia trachomatis as common pathogens . More recent studies report the predominance of opportunistic bacteria such as Staphylococcus species, Streptococcus species, and most commonly, Escherichia coli.

Differential Diagnoses

Workup

Laboratory Studies

• In otherwise healthy, afebrile adults, blood tests are not necessary to evaluate an uncomplicated abscess or cyst.
• Sexually transmitted disease (STD) testing should be available at the request of the patient; however, Bartholin abscesses are very rarely caused by sexually transmitted pathogens.
• Cultures are rarely useful in treatment of abscess; furthermore, routine culturing of drained fluid is not recommended.

Procedures

The following features are suggestive of Bartholin gland malignancy. Patients who present with any of these features should be referred to a gynecologist for biopsy:

• Age older than 40 years
• Chronic or gradually progressive, painless mass
• Solid, nonfluctuant, painless mass
• Prior history of labial malignancy

Treatment

Emergency Department Care

ED care should include a careful history and physical examination. A patient whose presentation is concerning for malignancy should receive close outpatient gynecologic follow-up for biopsy and possible excision. Those with an uncomplicated, asymptomatic cyst may be discharged with sitz bath instructions. Sitz baths (3 times daily) for several days may promote improvement with resolution or spontaneous rupture with resolution of the cyst.

A Bartholin abscess is generally painful, and, thus, usually requires incision and drainage. Several techniques have been described,^{[1 ]}but no large prospective studies have been performed to determine relative efficacy and complications. The goal of abscess treatment is to allow drainage and to prevent rapid reaccumulation of fluid. These techniques are described below. Refer to the eMedicine Clinical Procedures article Drainage, Bartholin Abscess for Bartholin cyst management and further details.

• Patient comfort is essential to successful drainage.
  • Use adequate anesthesia when incising any abscess. Attempting to do so without anesthesia results in an uncooperative patient, reduces the likelihood of successful drainage, and is unconscionable.
  • Apply topical anesthetics to the mucosa followed by submucosal injection of local anesthetic (the minimum pain control required).
  • Conscious sedation is often required and may be desirable. In patients with a large or complex abscess or for a complicated procedure, general anesthesia in the operating room (OR) may be required.
• Incision and drainage
  • This technique consists of traditional incision, drainage, irrigation, and packing.
  • Packing should be removed 2 days after the procedure.
  • This technique requires multiple, painful packing changes and has a higher rate of abscess recurrence.
• Word catheter (shown in the image below)
• 
  

  

  Word catheter.

  
  
  • The word catheter was introduced in the 1960s. It is a small catheter with a saline inflatable balloon at the distal end.
  • This procedure should be performed using sterile technique.
  • Using an #11 blade a 0.5-cm incision is made into the abscess cavity on the mucosal surface of the labia minora.
  • Contents of the cavity are expressed manually or by hemostat.
  • The tip of the catheter is inserted into the cavity, and the balloon is inflated with 4 mL normal saline, as shown in the image below.
  • 
    

    

    Word catheter with inflated balloon.

    
    
  • The free end of the catheter may be inserted into the vagina for patient comfort.
  • The catheter allows for abscess drainage acutely and is left in place for several weeks to promote fistula formation.
  • Patients should be advised to take sitz baths 2-3 times a day for 2 days following the procedure and to abstain from sexual intercourse until the catheter is removed.
  • Simplicity is the technique's main advantage. It is tolerable to patients and allows restoration of gland function.
  • A recent case report describes novel use of plastic tubing for abscess drainage when a Word catheter is not available.^{[2 ]}
• Marsupialization
  • This procedure is reserved for recurrent abscesses. The acute abscess is drained prior to marsupialization.
  • This procedure consists of a wide incision of the mass followed by suturing the inner edge of the incision to external mucosa.
  • This complicated procedure is usually performed by a gynecologist or urologist in the OR.
• Excision
  • This procedure requires excision of the Bartholin gland and surrounding tissue. It is disfiguring, painful, and seldom indicated in the treatment of abscess, although it may be used to treat malignancy.
  • It should be performed only in the OR to ensure appropriate anesthesia.
• Experimental techniques
  • Recent studies have examined the safety and efficacy of carbon dioxide laser therapy as well as alcohol sclerotherapy to treat Bartholin abscesses.^{[3,4 ]}Early studies show promising results. In a recent study, the cure rate was nearly 96% with one laser treatment.^{[5 ]}

Consultations

• Patients who present to the ED with Bartholin gland swelling rarely require emergent gynecologic consultation. Relative indications for consultation may include the following:
  • Complex or recurrent abscess requiring general anesthesia in the OR
  • Need for biopsy, usually due to concern for malignancy

Medication

Medications used in the treatment of Bartholin abscesses include topical and local anesthetics. Antibiotics for empiric treatment of STDs are advisable in the doses usually used to treat gonococcal and chlamydial infections. Ideally, antibiotics should be started immediately prior to incision and drainage.

Anesthetics

These agents may be used topically or as injectables. Topical anesthetic may be used on vaginal mucosa prior to submucosal injection.

Lidocaine (Dilocaine)

Decreases permeability to sodium ions in neuronal membranes. Inhibits depolarization, blocking the transmission of nerve impulses, which reduces pain.
Topical preparations are available in spray and ointment form.
Injectable lidocaine is available as 1% or 2% concentration, with or without epinephrine.

Dosing

Adult

Topical: Apply 3-5 mg/kg
Injection: 3-5 mg/kg in submucosa surrounding cyst

Pediatric

Apply as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity to amide-type local anesthetics; avoid in Adams-Stokes syndrome and Wolff-Parkinson-White syndrome; avoid in severe sinoatrial, atrioventricular, or intraventricular block, if artificial pacemaker not in place

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

For external or mucous membrane use only; do not use in eyes

Bupivacaine (Marcaine, Sensorcaine)

By increasing electrical excitation threshold, slowing nerve impulse propagation, and reducing the action potential, bupivacaine prevents the generation and conduction of nerve impulses to reduce pain.
Concentrations of 0.25% and 0.5% are commonly used for local infiltration. Duration of action is significantly longer than lidocaine. Bupivacaine is available with or without epinephrine.

Dosing

Adult

Maximum dose: 225 mg intralesionally with epinephrine; 175 mg without epinephrine; inject in submucosa surrounding cyst

Pediatric

<12 years: Not recommended
>12 years: Administer as in adults

Interactions

May reduce pain by slowing nerve impulse propagation and reducing action potential, which, in turn, prevents initiation and conduction of nerve impulses

Contraindications

Documented hypersensitivity; septicemia; spinal deformities; severe hypertension; existing neurologic disease

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Test a dose and monitor for CNS toxicity, cardiovascular toxicity, and signs of unintended intrathecal administration; caution with inflammation or sepsis in region of proposed injection; monitor patient's state of consciousness after each injection; caution in hypertension, cerebral vascular insufficiency, peripheral vascular disease or heart block, and arteriosclerotic heart disease

Antibiotics

Most Bartholin abscesses are caused by opportunistic pathogens. Uncomplicated abscesses in otherwise healthy women may not require antibiotic therapy after successful drainage. Treatment of N gonorrhoeae and C trachomatis should be initiated only in patients with confirmed disease.

Ceftriaxone (Rocephin)

An effective monotherapy against N gonorrhoeae, ceftriaxone is a third-generation cephalosporin with broad-spectrum efficiency against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to 1 or more of penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.

Dosing

Adult

125 mg IM as single dose

Pediatric

Infants and children: 50-75 mg/kg/d IV divided q12h; not to exceed 2 g/d

Interactions

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin

Ciprofloxacin (Cipro)

An alternative monotherapy to ceftriaxone. Bactericidal antibiotic that inhibits bacterial DNA synthesis and, consequently, growth by inhibiting DNA-gyrase in susceptible organisms.

Dosing

Adult

250 mg PO once

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Doxycycline (Bio-Tab, Doryx, Vibramycin)

Inhibits protein synthesis and bacterial replication by binding with 30S and, possibly, 50S ribosomal subunits of susceptible bacteria. Indicated for C trachomatis.

Dosing

Adult

100 mg PO bid for 7 d

Pediatric

<8 years: Not recommended
>8 years: 2-5 mg/kg PO qd or divided bid; not to exceed 200 mg/d

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Azithromycin (Zithromax)

Used to treat mild-to-moderate infections caused by susceptible strains of microorganisms. Alternative monotherapy for C trachomatis.

Dosing

Adult

1 g PO once

Pediatric

<6 months: Not established
>6 months: 10 mg/kg PO on d 1, followed by 5 mg/kg PO qd on d 2-5

Interactions

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients

Follow-up

Further Outpatient Care

• Most patients with Bartholin gland disease are discharged home. 
• Patients with Bartholin cyst or abscess should be advised to take warm sitz baths 3 times per day for several days.
• Patients with an abscess often feel immediate pain relief after the drainage procedure; however, they may require oral analgesia for several days after the procedure.
• All patients with a Bartholin gland mass should receive close gynecologic follow-up.

Complications

• The most common complication of treatment of Bartholin abscess is recurrence.
• Rare case reports exist of necrotizing fasciitis after abscess drainage.
• A theoretical risk exists for development of toxic shock syndrome with packing.
• Nonhealing wounds may occur.
• Bleeding, especially in patients with a coagulopathy, may be a complication.
• Cosmetic scarring may result.

Prognosis

• If abscesses are properly drained and reclosure is prevented, most abscesses have a good outcome.
• Recurrence rates are generally reported to be less than 20%.

Patient Education

• For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center and Women's Health Center. Also, see eMedicine's patient education article Bartholin Cyst.

Miscellaneous

Medicolegal Pitfalls

• Failure to consider the possibility of malignancy as an alternative cause of the mass
• Failure to provide a gynecologic consultation to any patient with a clinical presentation consistent with malignancy

Multimedia

Media file 1: Word catheter.

Media file 2: Word catheter with inflated balloon.

Media file 3: Bartholin abscess.

References

1. Wechter ME, Wu JM, Marzano D, Haefner H. Management of Bartholin duct cysts and abscesses: a systematic review. Obstet Gynecol Surv. Jun 2009;64(6):395-404. [Medline].

2. Kushnir VA, Mosquera C. Novel technique for management of Bartholin gland cysts and abscesses. J Emerg Med. May 2009;36(4):388-90. [Medline].

3. de Góis Speck NM, Belfort PN, Mendes P, Kang HJ, Ribalta JC. Carbon dioxide laser treatment of Bartholin's gland cyst. Clin Exp Obstet Gynecol. 2007;34(1):50-1. [Medline].

4. Benedetti Panici P, Manci N, Bellati F, Di Donato V, Marchetti C, Calcagno M, et al. CO2 laser therapy of the Bartholin's gland cyst: surgical data and functional short- and long-term results. J Minim Invasive Gynecol. May-Jun 2007;14(3):348-51. [Medline].

5. Fambrini M, Penna C, Pieralli A, Fallani MG, Andersson KL, Lozza V, et al. Carbon-dioxide laser vaporization of the Bartholin gland cyst: a retrospective analysis on 200 cases. J Minim Invasive Gynecol. May-Jun 2008;15(3):327-31. [Medline].

6. Aghajanian A, Bernstein L, Grimes DA. Bartholin's duct abscess and cyst: a case-control study. South Med J. Jan 1994;87(1):26-9. [Medline].

7. Eppel W, Frigo P, Worda C, Bettelheim D. Ultrasound imaging of Bartholin's cysts. Gynecol Obstet Invest. 2000;49(3):179-82. [Medline].

8. Goldberg JE. Simplified treatment for disease of Bartholin's gland. Obstet Gynecol. Jan 1970;35(1):109-10. [Medline].

9. Heah J. Methods of treatment for cysts and abscesses of Bartholin's gland. Br J Obstet Gynaecol. Apr 1988;95(4):321-2. [Medline].

10. Kdous M, Hachicha R, Iraqui Y, Jacob D, Piquet PM, Truc JB. [Necrotizing fasciitis of the perineum secondary to a surgical treatment of Bartholin's gland abscess]. Gynecol Obstet Fertil. Nov 2005;33(11):887-90. [Medline].

11. Tanaka K, Mikamo H, Ninomiya M, Tamaya T, Izumi K, Ito K, et al. Microbiology of Bartholin's gland abscess in Japan. J Clin Microbiol. Aug 2005;43(8):4258-61. [Medline].

12. Wheelock JB, Goplerud DR, Dunn LJ, Oates JF 3rd. Primary carcinoma of the Bartholin gland: a report of ten cases. Obstet Gynecol. Jun 1984;63(6):820-4. [Medline].

13. Woida FM, Ribeiro-Silva A. Adenoid cystic carcinoma of the Bartholin gland: an overview. Arch Pathol Lab Med. May 2007;131(5):796-8. [Medline].

14. Wydra D, Klasa-Mazurkiewicz D, Emerich J, Milczek T. The problem of accurate initial diagnosis of Bartholin's gland carcinoma resulting in delayed treatment and aggressive course of the disease. Int J Gynecol Cancer. May-Jun 2006;16(3):1469-72. [Medline].

Keywords

Bartholin gland cyst, Bartholin gland swelling, Bartholin gland abscess, Bartholin's gland, Bartholin's cyst, Bartholin cyst, Bartholin abscess, Bartholin's abscess, bartholinitis, Neisseria gonorrhoeae, N gonorrhoeae, Chlamydia trachomatis, C trachomatis, Bartholin gland drainage

Contributor Information and Disclosures

Author

Jennifer Coles Schecter, MD, Staff Physician, Department of Emergency Medicine, Lahey Clinic, Burlington, MA
Disclosure: Nothing to disclose.

Coauthor(s)

Antonia Quinn, DO, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate Medical Center/Kings County Hospital Center; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Antonia Quinn, DO is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Joseph J Sachter, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Muhlenberg Regional Medical Center
Joseph J Sachter, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Howard A Blumstein, MD, to the development and writing of this article.

The authors and editors of eMedicine gratefully acknowledge the medical review of this article by Tyson Pillow, MD.

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