eMedicine Specialties > Emergency Medicine > Genitourinary
Bartholin Gland Diseases: Treatment & Medication
Updated: Dec 2, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
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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
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.
Adult
Topical: Apply 3-5 mg/kg
Injection: 3-5 mg/kg in submucosa surrounding cyst
Pediatric
Apply as in adults
None reported
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
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.
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
May reduce pain by slowing nerve impulse propagation and reducing action potential, which, in turn, prevents initiation and conduction of nerve impulses
Documented hypersensitivity; septicemia; spinal deformities; severe hypertension; existing neurologic disease
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.
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
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
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.
Adult
250 mg PO once
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
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)
Documented hypersensitivity
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.
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
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
Documented hypersensitivity; severe hepatic dysfunction
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.
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
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
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
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
More on Bartholin Gland Diseases |
| Overview: Bartholin Gland Diseases |
| Differential Diagnoses & Workup: Bartholin Gland Diseases |
 Treatment & Medication: Bartholin Gland Diseases |
| Follow-up: Bartholin Gland Diseases |
| Multimedia: Bartholin Gland Diseases |
| References |
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References
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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].
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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].
Further Reading
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
