Bartholin Gland Marsupialization

Background

The greater vestibular glands (commonly known as the Bartholin glands) make up an important part of the female reproductive system. The Bartholin glands have a primary function of secreting mucus to help provide vulvar and vaginal lubrication. ^[1]  To fulfill this purpose, each Bartholin gland contains a duct that measures approximately 5 mm in diameter in the average female. For proper secretion, the epithelium of each gland is columnar in nature, while the epithelium of each duct is simple. The orifice is of the stratified squamous type. The secretion produced is a thick, mucoid, clear substance with a basic pH, and it provides lubrication during sexual activity. ^[2]

Measuring from 1.5-2 cm on average, each Bartholin gland is oval in shape and resides just inferior and lateral to the bulbocavernosus muscle. Innervation is received from a small branch of the perineal nerve, while arterial blood supply is received from a small branch of the artery on the bulbocavernosus muscle. Likewise, venous drainage is also via vessels on the bulbocavernosus muscle. Lymphatics are via the vestibular plexus and pudendal vessels, and this drainage route is important to consider when in-depth surgery is needed. ^[2] See the image below.

If a gland becomes infected or a duct becomes obstructed, the result is often the development of a Bartholin cyst or abscess that may require medical attention. ^{[3, 4]} This occurs in 2% of women. In addition, in rare cases, malignancy of the Bartholin gland can occur. ^[5] See the images below.

Treatment options for Bartholin gland cysts or abscesses include expectant management, sitz baths, antibiotics, Word catheter placement, marsupialization, and gland excision. ^{[6, 7]}  There has been no proven superiority between surgical and conservative management strategies. ^{[8, 9]}

This article discusses marsupialization, in which the cyst is opened and the edges sutured, forming an "open pocket" or "pouch."

Indications

Indications for marsupialization are as follows:

• History of recurrent Bartholin gland cysts or abscesses

• Significant patient pain or discomfort

• Failure of cyst resolution in a timely manner or with alternative treatments

• Patient declines or cannot tolerate Word catheter placement in an office setting

Contraindications

Contraindications to marsupialization are few and far between, with patient refusal being virtually the only one identified.

Technical considerations

Several things must be considered when deciding to perform a Bartholin gland marsupialization. These questions help to guide the choice of procedure location as well as preoperative, intraoperative, and postoperative treatment. Each of these is briefly addressed:

• Is this a procedure that must be performed in the operating room, or could an alternative procedure such as Word catheter placement be performed in the office?

• Is it strictly a Bartholin cyst or is it a Bartholin abscess?

• If it is an abscess, what are the organisms involved and are they being treated adequately?

• Is the patient immunocompromised?

• Are there comorbidities that may make postoperative healing a problem?

• Is there significant concern for malignancy?

Word catheterization and marsupialization

For information on Word catherization of Bartholin gland cyst or abscess, please see Bartholin Abscess Drainage.

In general, the effectiveness, complication rates, and recurrence rates  are similar between marsupialization and Word catheterization. ^[9]

In a study of 30 Austrian women with Bartholin cyst or abscess that evaluated office implementation, recurrence rates, and costs between Word catheterization and marsupialization, investigators noted an 87% success rate and 3.8% recurrence rate in women treated using the Word cathether. ^[8]  Word catherization was simpler to use and cost seven-fold less than marsupialization.

In a different analysis, the investigators also evaluated quality of life and sexual activity during and following treatment of Bartholin cyst or abscess with Word catherization and reported improved pain levels as well as significantly improved pain/discomfort dring sexual activity. ^[10] The mental component summary score of the quality of life evaluation showed a significant improvement after treatment compared with the pretreatment period, although the physical component summary score did not show a significant change. ^[10]

Anesthesia

The typical anesthesia used for a Bartholin gland marsupialization is procedural sedation, a local anesthetic alone, or a combination of the two.

A local anesthetic (eg, lidocaine, mepivacaine) should be administered and may minimize postoperative discomfort. Including a vasoconstrictive agent, such as epinephrine, with the local anesthetic may be beneficial. Although bleeding is usually minimal for the procedure, this step may help during those few times when bleeding may otherwise cloud the surgical field. For more information, see Infiltrative Administration of Local Anesthetic Agents.

The anesthesiologist usually chooses the anesthetic. Depending on body habitus, airway distortion, or prior history of adverse reactions to anesthesia, the anesthesiologist may decide that general anesthesia, which requires intubation, may be the best method, and procedural sedation may be forgone. Given that most marsupializations are relatively quick procedures, this happens rarely.

Equipment

Equipment needed for the procedure consists of the following ^[11] :

• Scalpel

• Pickups/tissue forceps

• Sponges (laparotomy or 4 x 4 gauze sponges)

• Scissors (Mayo, Metzenbaum)

• Allis clamps

• Absorbable suture; options and acceptable sizes vary and include the following: Polysorb (usually 2-0 or 3-0); Vicryl (usually 2-0 or 3-0); Chromic (usually 2-0 or 3-0); and Caprosyn (usually 2-0 or 3-0).

• Culture swab and tube - Optional

• Povidone iodine (eg, Betadine) or alternative prep cleanser such as iodine povacrylex/isopropyl alcohol (eg,DuraPrep)

• Foley catheter or straight catheter - Optional

• Bovie cautery - Optional

• Small hemostatic clamps (Criles or Mosquitoes)

• Local anesthetic - Optional

Positioning

To ensure proper positioning, care must be taken to place the patient carefully in the lithotomy position. Stirrup choices include Yellow Fin, Allen, and Candy Cane. Proper positioning for any type of gynecological procedure is key to prevent unwanted injury to pelvic, buttock, or groin vasculature or nerve. See the image below.

Part of positioning the patient includes draping the patient appropriately. Sterile drapes or towels must cover unwanted areas while allowing the surgeon adequate exposure to the operative site. A sterile towel may be placed over the anal area to guard against anal and rectal bacteria.

Complication prevention

The operative area should be prepared with an antimicrobial solution such as Betadine. Given that the vulva and vagina are closely linked, a vaginal prep/cleansing should also be performed. Avoidance of cross-contamination from the anal area is important, because bacteria in that area are numerous and can be easily transferred to the vulvar area. If care is not taken, cross-contamination can lead to a postoperative wound infection in women who initially present for marsupialization of a known uninfected cyst.

Depending on the timeframe between diagnosis and procedure, the patient may have already been on broad spectrum antibiotics if cellulits was noted or an abscess was suspected. In the case of a simple Bartholin gland cyst, antibiotics are usually not used.

The technique may be summarized as follows ^{[12, 13, 14]} :

• Once the patient is properly anesthetized, a thorough bimanual examination should be performed. This helps the surgeon determine the borders and extent of the cyst or abscess. Once properly prepped and draped, the bladder is drained with a straight catheter. A Foley catheter can be placed at the discretion of the surgeon.

• The labia are retracted digitally and the introitus is exposed so that the entire surgical field is visualized. If local anesthetic is to be used, it is applied to the area immediately surrounding the cyst with care taken not to enter or puncture the cyst wall.

• A 1.5- to 2-cm vertical incision is then made over the mucosa just distal to the hymenal ring and on the wall of the gland at the cyst site. Care must be taken to ensure that the opening into the gland is sufficient to promote adequate drainage. Any bleeding noted can be controlled with sponges or suction.

• The wall of the gland is then incised and the cyst contents are evacuated. This can be accomplished with gentle expression or with irrigation. At this point, cultures of the fluid are obtained and sent to the lab.

• The walls of the cyst are grasped with Allis clamps. Absorbable suture such as Polysorb or Vicryl is used in an interrupted or continuous fashion to suture the wall of the cyst to the introitus laterally and the vaginal mucosa medially. The marsupialization is now complete.

Postoperative care

After the procedure, the patient is usually placed on a regimen that includes the following:

• Hot sitz baths starting postoperative day 1 or 2

• Oral pain medication such as ibuprofen, acetaminophen, or an appropriate narcotic if pain is severe

• Antibiotics are not routinely prescribed for Bartholin gland cysts unless there is evidence of cellulitis. Broad-spectrum antibiotics can then be used. For Bartholin gland abscesses, broad-spectrum antibiotics can also be administered until final culture results are obtained. ^[6]  Antibiotic administration has not been shown to prevent recurrence. ^[15]

• The patient may resume sexual intercourse by 4 weeks after surgery.

Complications

Complications vary in their risk of development and can include recurrence, postoperative infection, dyspareunia and unresolved pain, scarring, and neuropathy (rare).

Recurrence

Recurrence rates range from 2% to 25% with varying periods of follow-up considered.

A study by Randall and Downs found that 63% of their study population (12 out of 19) reported a total of 28 incision and drainage procedures prior to marsupialization. After marsupialization, none of these patients had a recurrence in the first 1 week after surgery. ^[16]

Andersen et al compared marsupialization alone to primary suture technique plus antibiotic coverage in 19 patients with Bartholin gland abscesses. They found no significant difference in recurrence rates between the two groups at 6 month follow-up. ^[17]

Postoperative infection

Postoperative infection can be due to preexisting Neisseria gonorrhoeae or Chlamydia trachomatis infection. Prophylactic antibiotics are not usually administered preoperatively for uncomplicated Bartholin gland cysts.

Postoperative infection can be polymicrobial in origin, and it can have bacteria commonly associated with the gastrointestinal tract owing to its proximity to the vulva.

Dyspareunia and unresolved pain

These may be associated with the size of the cyst/abscess and the size of the operative site.

Long-term monitoring

It is important to evaluate patients who have undergone Bartholin gland marsupialization at their well woman visits for any signs or symptoms consistent with suspected healing difficulties or recurrence. In addition, it is important to discuss any new symptoms that have arisen since the procedure, such as dyspareunia, vaginal discharge, and vulvar or labial numbness. If found early, these symptoms can be evaluated and addressed appropriately to provide patient care and comfort.

Medication summary

Infections of the Bartholin gland can be associated with N gonorrhoeae and C trachomatis infections. A study of emergency department patients with a Bartholin cyst or abscess found that 10% were infected with N gonorrhoeae. ^[18]

Infections are also often polymicrobial in nature. As such, they frequently require broad-spectrum antibiotic coverage. Antibiotic choices for Bartholin gland infections are numerous. Likewise, the same can be said for local anesthetics often used during the marsupialization procedure. An overview of both is listed below and can also be found in Bartholin Gland Diseases.

Common antibiotics used include the following:

• Ceftriaxone (broad-spectrum and N gonorrhoeae coverage)

• Ciprofloxacin (broad-spectrum coverage)

• Doxycycline (C trachomatis coverage)

• Azithromycin (C trachomatis coverage)

Common local anesthetics include the following:

• Lidocaine: 1% or 2% concentrations available; used with or without epinephrine
• Bupivicaine (Marcaine, Sensorcaine): 0.25% or 0.5% concentrations available; used with or without epinephrine