Bartholin Gland Diseases Treatment & Management

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)

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.

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]

Silver nitrate gland ablation has shown promise as a safe and effective treatment for both simple cysts and abscesses in a number of small studies.^[1]

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