Bartholin Gland Diseases Treatment & Management

Updated: Oct 24, 2022
  • Author: Antonia Quinn, DO; Chief Editor: Erik D Schraga, MD  more...
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Treatment

Approach Considerations

Women with a Bartholin gland cyst usually are first seen by the primary care provider, nurse practitioner, or internist. Because of the extensive differential, it is important to involve the gynecologist in the care of these patients. Antibiotic therapy should be considered for (1) those who have failed initial incision and drainage with Word catheter placement' (2) patients with systemic symptoms including fever; (3) patients who have suspected sepsis; and (4) those considered at high risk for recurrence. Women who are pregnant who have Bartholin abscesses should be treated in the same manner as nonpregnant women, with the exception of Bartholin gland excision due to increased risk of bleeding. [19]

Numerous options are available for the treatment of symptomatic Bartholin cysts or abscesses. The most common interventions include incision, drainage with Word catheter placement, and abscess marsupialization. Randomized trial evidence does not support the use of any single surgical method. Outcomes of other interventions such as rubber ring catheter insertion, cavity closure, and alcohol sclerotherapy have not been sufficiently studied. [1]

Patients who present to the ED with Bartholin gland swelling rarely require emergent gynecologic consultation. Relative indications or consultation may include the following:

  • Complex or recurrent abscess requiring general anesthesia in the OR/

  • Need for biopsy, usually due to concern for malignancy.

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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. [11]

A Bartholin abscess is generally painful and therefore usually requires incision and drainage. Several techniques have been described, [20] 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.

Patient comfort is essential to successful drainage. Adequate anesthesia is necessary when incising any abscess. Apply topical anesthetics to the mucosa followed by submucosal injection of local anesthetic (the minimum pain control required). Procedural sedation 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.

In a study of patients with Bartholin gland carcinoma, high-dose-rate interstitial brachytherapy (HDR-ISBT) boost after external-beam radiation therapy (EBRT) was shown to provide excellent long-term local control. According to the authors, HDR-ISBT should be considered for positive surgical margins or residual tumor after surgery and for locally advanced malignancies treated by primary chemoradiotherapy. [21]

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.

The Word catheter (see the images below) 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. In one study, Word catheter treatment was successful in 26 of 30 cases (87%) of Bartholin cyst or abscess. [10] 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. [10, 12, 17]

Word catheter. (Image courtesy of Dr. Gil Shlamovi Word catheter. (Image courtesy of Dr. Gil Shlamovitz.)

 

Word catheter with inflated balloon. (Image courte Word catheter with inflated balloon. (Image courtesy of Dr. Gil Shlamovitz.)

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. [22]

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. [12, 17]

A comparison of sexual functioning scores in patients who had marsupialization and gland excision procedures for the treatment of Bartholin gland abscesses found dyspareunia after the procedure was more common in patients who underwent marsupialization (2.9% vs 15.1%, P=0.01). The Female Sexual Function Index (FSFI) scores were less than 26.5 in both treatment groups. The total score was 24.76 ± 4.32 in the excision group and was 22.33 ± 5.15 in the marsupialization group. [23]

In the WoMan trial (Word catheter and marsupialization in women with a cyst or abscess of the Bartholin gland), a randomized controlled trial conducted in the Netherlands and in England between August 2010 and May 2014, 161 women were randomly allocated to treatment by Word catheter or marsupialization to compare recurrence of a cyst or abscess within 1 year. Recurrence occurred in 10 women (12%) in the Word catheter group and in 8 women (10%) in the marsupialization group. Within the first 24 hours after treatment, 33% in the Word catheter group used analgesics versus 74% in the marsupialization group. Time from diagnosis to treatment was 1 hour for placement of the Word catheter versus 4 hours for marsupialization. Recurrence rates in the 2 groups were comparable; however, the marsupialization group showed increased use of analgesics within the first 24 hours and increased duration of treatment. [2]

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.

Other techniques

Carbon dioxide laser therapy can provide cyst vaporization in the outpatient setting. A prospective, randomized trial found that silver nitrate ablation following cyst drainage was as effective as marsupialization and caused less scar formation. Researchers concluded that procedures such as cyst/abscess fenestration and needle aspiration with or without alcohol sclerotherapy require further clinical research. [1]

Some studies have examined the safety and efficacy of carbon dioxide (CO2) laser therapy, as well as alcohol sclerotherapy, to treat Bartholin abscesses. [24, 25, 26] Early studies have shown promising results. In one study, the cure rate was nearly 96% with one laser treatment. [27]

In another study of patients who received carbon dioxide laser therapy, the median operative time was 15 minutes (range, 12-35 min); median postoperative stay was 1 hour (range, 1-4 hr; stimated 3-yr relapse-free rate, 88.56%). Lesion wall thickness of 0.5-1.5 mm, multilocular lesions, and hyperechogenic lesions were correlated with recurrence. [28]

A pilot study compared the impact of CO laser therapy on sexual function with patients affected by a Bartholin gland cyst or abscess treated with surgical cold knife treatment. A statistically significant advantage of CO laser versus cold knife treatment was found in terms of lubrication, pain, and global score. [29]

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. [20]

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Medical 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.

The prognosis for patients with Bartholin gland disease is excellent, but high recurrence rates have been reported following simple cyst aspiration. Healing and recurrence rates are similar among fistulization, marsupialization, and silver nitrate and alcohol sclerotherapy. Needle aspiration and incision and drainage—the 2 simplest procedures—are not recommended because of relatively high recurrence rates. [2]

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Complications

Treatment of patients with Bartholin gland cysts by traditional surgery is characterized by disadvantages and complications such as hemorrhage, postoperative dyspareunia, infection, and the need for general anesthesia. It has been found that CO2 laser surgery might be less invasive and more effective, solving many of the problems of traditional surgery. [2]

The most common complication of treatment of Bartholin abscess is recurrence. Rare case reports exist of necrotizing fasciitis after abscess drainage. Nonhealing wounds may occur. Bleeding, especially in patients with a coagulopathy, may be a complication. Cosmetic scarring may result.

A theoretical risk exists for development of toxic shock syndrome with packing.

A case of cauda equina syndrome following neuraxial anesthesia for drainage of a Bartholin abscess has been reported. [30]

 

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