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eMedicine Specialties > Clinical Procedures > Obstetric and Gynecologic Procedures

Drainage, Bartholin Abscess

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT

Updated: May 21, 2009

Introduction

Bartholin abscesses and cysts account for 2% of all gynecological visits per year.1 The Bartholin glands are a pair of pea-sized, vulvovaginal, mucous-secreting vestibular glands that are located in the labia minora in the 4- and 8-o’clock positions, beneath the bulbospongiosus muscle. A Bartholin cyst is a fluid-filled sac that develops in one of the Bartholin glands or ducts when the duct that drains the fluid from the gland becomes blocked and causes the duct and gland to swell. A Bartholin gland abscess develops either when a Bartholin cyst becomes infected or when the Bartholin gland itself becomes infected.2 For more information on disorders of the Bartholin gland, please see Bartholin Gland Diseases and Benign Vulvar Lesions.

Different techniques exist for the treatment of Bartholin cysts and abscesses.3,4 Use of the Word catheter is favored.5,6 If a Word catheter is not available, incision and drainage (with traditional packing) may be performed.

Indications

  • Selected Bartholin cysts
    • Diameter of 1 cm or larger
    • Any symptomatic cyst (painful, tender, interferes with physical or sexual activity)
  • Any Bartholin abscess

Contraindications

  • Absolute - None
  • Relative - Complex or recurrent abscess that requires general anesthesia in the operating room

Anesthesia

  • Incision and drainage of a Bartholin cyst or abscess requires anesthesia of the labial mucosa. Because infiltration of the labial mucosa with a local anesthetic may be painful, discuss options such as intravenous narcotics and procedural sedation and analgesia with each patient.
  • See Technique for the procedure for local anesthetic infiltration. For more information, see Local Anesthetic Agents, Infiltrative Administration.

Equipment

  • Sterile skin preparatory solution and drapes
  • Lidocaine 1%
  • Normal saline (0.9% NaCl)

  • Normal saline (0.9% NaCl).

    Normal saline (0.9% NaCl).


  • Syringe, 3 mL
  • Syringe, 5 mL
  • Syringe, 10 mL
  • Needles, 18 gauge (3)
  • Needle, 25 or 27 gauge, 1.5 inch (for injection of anesthesia)
  • Scalpel blade (No. 11) and handle
  • Gauze pads (4 X 4)
  • Hemostat
  • Culture swab
  • Word catheter

  • Word catheter.

    Word catheter.



  • Word catheter with inflated balloon.

    Word catheter with inflated balloon.


Positioning

  • Place the patient in the lithotomy position.

Technique

  • Explain the procedure, risks, benefits, possible complications, alternative options, and postprocedure care to the patient or her legal representative and obtain a written informed consent. A female chaperone should be present in the procedure room throughout the procedure.
  • Place the patient in the lithotomy position and spread open the labia. An assistant may aid with traction of the labia during the procedure.

  • Bartholin abscess.

    Bartholin abscess.


  • Use the sterile skin preparatory solution to clean the labia and surrounding area.

  • Skin preparation.

    Skin preparation.


  • Infiltrate 2-3 mL of lidocaine 1% subcutaneously under the mucosa of the labia minora.

  • Mucosal infiltration with lidocaine.

    Mucosal infiltration with lidocaine.



  • Mucosal infiltration with lidocaine.

    Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79930-80260-110997.flv.


  • Large abscesses or cysts may be needle-decompressed prior to incision with the blade.

  • Needle aspiration.

    Needle aspiration.



  • Needle aspiration.

    Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79930-80260-111002.flv.


  • Incision is made in the vestibular area close to the hymen through an area of fluctuation.7 Use a No. 11 blade to make a puncture 0.5-1 cm long into the abscess or cyst cavity on the mucosal surface of the labia minora. Make the incision within the hymenal ring, if possible.

  • Incision of Bartholin abscess.

    Incision of Bartholin abscess.



  • Incision of Bartholin abscess.

    Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79930-80260-111004.flv.


  • Express the contents of the sac manually and use the hemostat to break adhesions. The contents may be sent for culture, and a suction system can be used to contain the manually-expressed fluids.

  • Drainage of a Bartholin abscess.

    Drainage of a Bartholin abscess.


  • Insert the tip of the Word catheter deep into the abscess cavity and use 2-4 mL of normal saline to inflate the balloon.

  • Insertion of a Word catheter.

    Insertion of a Word catheter.



  • Inflation of a Word catheter.

    Inflation of a Word catheter.



  • Insertion and inflation of a Word catheter.

    Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79930-80260-111013.flv.


  • Tuck the free end of the catheter into the vagina. In many cases, the free end changes its position to protrude outside the vagina. The catheter should stay in place for up to 4 weeks to allow epithelization of the tract. The patient should abstain from vaginal intercourse while the catheter is in place.

  • Word catheter in place.

    Word catheter in place.


  • The Word catheter may be left in place for several weeks to minimize the chance of recurrence. When healing is completed, a small permanent fistula is created in between the cyst cavity and the vestibular area. The size of the ostium is very small and scarcely visible with time.7

Pearls

  • Antibiotic treatment is at the discretion of the treating clinician. Antibiotics are not usually indicated in the immunocompetent patient with a drained Bartholin abscess.
  • When a Word catheter is not available, a simple incision and drainage with packing can be performed. Warn the patient of the high probability of abscess recurrence and refer the patient to a gynecologist.6 Gauze packing is removed after 24-48 hours.7
  • All patients should be instructed to begin sitz baths 1-2 days postprocedure and to abstain from vaginal intercourse until the Word catheter or packing is removed.
  • Prescribe analgesics and refer patients to a gynecologist for follow-up.
  • Patients older than 40 years should be referred to a gynecologist for a biopsy to rule out Bartholin gland cancer.
  • Patients with multiple recurrences with previous treatments should be referred to a gynecologist for definitive treatment (complete excision).

Complications

  • Recurrence
    • Recurrence is the most common complication after incision and drainage.
    • Premature dislodgement of the Word catheter results in incision closure and high rates of recurrence.
  • Missed diagnosis of Bartholin duct carcinoma8,9
    • Malignant tumors of the vulvar soft tissue are very uncommon. When localized in the Bartholin gland area, these tumours can be mistaken for benign lesions, leading to a delayed diagnosis.10 This rare form of carcinoma has an approximate incidence of 0.1 cases per 100,000 women.
    • Women older than 40 years should be referred to a gynecologist for diagnosis and treatment.11
  • Bleeding
  • Progressive infection and sepsis12
    • Patients with compromised immune systems may exhibit these rare complications.
    • Treat all immunocompromised patients with antibiotics. Closely monitor or even admit such patients in order to diagnose and treat progression to a deeper-seated infection.

Multimedia

Word catheter.

Media file 1: Word catheter.

Word catheter with inflated balloon.

Media file 2: Word catheter with inflated balloon.

Bartholin abscess.

Media file 3: Bartholin abscess.

Skin preparation.

Media file 4: Skin preparation.

Mucosal infiltration with lidocaine.

Media file 5: Mucosal infiltration with lidocaine.

Media file 6: Mucosal infiltration with lidocaine.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79930-80260-110997.flv.

Needle aspiration.

Media file 7: Needle aspiration.

Media file 8: Needle aspiration.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79930-80260-111002.flv.

Incision of Bartholin abscess.

Media file 9: Incision of Bartholin abscess.

Media file 10: Incision of Bartholin abscess.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79930-80260-111004.flv.

Normal saline (0.9% NaCl).

Media file 11: Normal saline (0.9% NaCl).

Drainage of a Bartholin abscess.

Media file 12: Drainage of a Bartholin abscess.

Insertion of a Word catheter.

Media file 13: Insertion of a Word catheter.

Inflation of a Word catheter.

Media file 14: Inflation of a Word catheter.

Media file 15: Insertion and inflation of a Word catheter.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79930-80260-111013.flv.

Word catheter in place.

Media file 16: Word catheter in place.

References

  1. Pundir J, Auld BJ. A review of the management of diseases of the Bartholin's gland. J Obstet Gynaecol. Feb 2008;28(2):161-5. [Medline].

  2. Singh N, Thappa DM, Jaisankar TJ, Habeebullah S. Pattern of non-venereal dermatoses of female external genitalia in South India. Dermatol Online J. Jan 15 2008;14(1):1. [Medline].

  3. Marzano DA, Haefner HK. The bartholin gland cyst: past, present, and future. J Low Genit Tract Dis. Jul 2004;8(3):195-204. [Medline].

  4. Cobellis PL, Stradella L, De Lucia E, Iannella I, Pecori E, Scaffa C, et al. Alcohol sclerotherapy: a new method for Bartholin gland cyst treatment. Minerva Ginecol. Jun 2006;58(3):245-8. [Medline].

  5. Hill DA, Lense JJ. Office management of Bartholin gland cysts and abscesses. Am Fam Physician. Apr 1 1998;57(7):1611-6, 1619-20. [Medline]. [Full Text].

  6. Omole F, Simmons BJ, Hacker Y. Management of Bartholin's duct cyst and gland abscess. Am Fam Physician. Jul 2003;68(1):135-40. [Medline].

  7. Lowenstein L, Solt I. Bartholin's cyst marsupialization. J Sex Med. May 2008;5(5):1053-6. [Medline].

  8. 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].

  9. Yang SY, Lee JW, Kim WS, Jung KL, Lee SJ, Lee JH, et al. Adenoid cystic carcinoma of the Bartholin's gland: report of two cases and review of the literature. Gynecol Oncol. Feb 2006;100(2):422-5. [Medline].

  10. Gonzalez-Bugatto F, Anon-Requena MJ, Lopez-Guerrero MA, Baez-Perea JM, Bartha JL, Hervías-Vivancos B. Vulvar leiomyosarcoma in Bartholin's gland area: a case report and literature review. Arch Gynecol Obstet. Feb 2009;279(2):171-4. [Medline].

  11. Gadducci A, Cionini L, Romanini A, Fanucchi A, Genazzani AR. Old and new perspectives in the management of high-risk, locally advanced or recurrent, and metastatic vulvar cancer. Crit Rev Oncol Hematol. Dec 2006;60(3):227-41. [Medline].

  12. Lopez-Zeno JA, Ross E, O'Grady JP. Septic shock complicating drainage of a Bartholin gland abscess. Obstet Gynecol. Nov 1990;76(5 Pt 2):915-6. [Medline].

  13. Cunningham G, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 22nd ed. New York, NY: McGraw-Hill; 2005.

  14. Lindsay K. Reichman E, Simon RR, eds. Emergency Medicine Procedures. New York, NY: McGraw-Hill; 2004.

Keywords

Bartholin abscess, Bartholin's gland, abscess, abscesses, abscess treatment, Bartholin cyst, Word catheter, Bartholin gland drainage, Bartholin gland swelling, incision and drainage, abscess drainage, cyst drainage, Bartholin gland, cyst treatment, vulvar cyst, vulvar abscess, vulva abscess

Contributor Information and Disclosures

Author

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

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