Bartholin Abscess Drainage

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. ^[2] A Bartholin gland abscess develops either when a Bartholin cyst becomes infected or when the Bartholin gland itself becomes infected. ^[3] For more information on disorders of the Bartholin gland, please see Medscape Reference articles Bartholin Gland Diseases and Benign Vulvar Lesions.

Although empiric antibiotic therapy is not indicated in the immunocompetent patient who presents with Bartholin gland abscess without cellulitis, it is helpful to know that a substantial proportion of patients with Bartholin gland abscess are culture positive, with Escherichia coli being the single most common pathogen. ^[4]

Different techniques exist for the treatment of Bartholin cysts and abscesses, but there has been no proven superiority between surgical and conservative management strategies. ^[5] The most commonly used approaches are: (1) fistulization using a Word catheter and (2) marsupialization. ^[6]

Other techniques include: (1) silver nitrate gland ablation; (2) cyst or abscess fenestration, ablation, or excision using carbon dioxide (CO₂) laser; (3) needle aspiration with or without alcohol sclerotherapy; (4) gland excision; and (5) incision and drainage followed by primary suture closure. ^{[7, 8, 9]}

No recurrence after marsupialization has been reported in available studies. Recurrence rates after other treatments has varied; recurrence was most common after aspiration alone (approximately 38%). Healing generally occurred in 2 weeks or less.

Although a review of the literature failed to identify a best treatment approach for the first occurrence of a symptomatic Bartholin cyst or abscess, the author recommends the use of the Word catheter as an initial approach. ^{[9, 10, 11]} If a Word catheter is not available, incision and drainage (with traditional packing) may be performed.

Incision and drainage is indicated for selected Bartholin cysts that have a diameter of 1 cm or larger or are symptomatic (painful, tender, interferes with physical or sexual activity) and/or any Bartholin abscess.

There are no absolute contraindications for Bartholin cyst or abscess incision and drainage. Relative contraindications include a complex or recurrent abscess that requires drainage under general anesthesia in the operating room.

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 the Technique section below for the procedure for local anesthetic infiltration. For more information, see Local Anesthetic Agents, Infiltrative Administration.

Equipment used in the incision and drainage of a Bartholin cyst or abscess include the following:

• Sterile skin preparatory solution and drapes

• Lidocaine 1%

• 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 (see images below)

  Word catheter.

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  Word catheter with inflated balloon.

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Place the patient in the lithotomy position.

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 (see image below). An assistant may aid with traction of the labia during the procedure.

Use the sterile skin preparatory solution to clean the labia and surrounding area (see image below).

Infiltrate 2-3 mL of lidocaine 1% subcutaneously under the mucosa of the labia minora (see image and video below).

Large abscesses or cysts that seem to be under high pressure may be partially needle-decompressed prior to incision with the blade in order to prevent high-pressure drainage upon incision (see image and video below). Complete needle decompression could make it harder to ensure proper identification of the abscess cavity and should be avoided.

An incision is made in the vestibular area through an area of fluctuation (see image and video below). ^[12] 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. If Word catheter placement is planned, the incision should be just larger than the catheter diameter. If the incision is too large, the patient will not be able to retain the catheter for the desired time. Conversely, if standard incision and drainage is performed, the larger incision is important.

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

Insert the tip of the Word catheter deep into the abscess cavity and use 2-4 mL of normal saline to inflate the balloon (see images and video below).

Tuck the free end of the catheter into the vagina. In many cases, the free end changes its position to protrude outside the vagina (see image below). 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.

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. ^[12]

Marsupialization and Word catheterization

Marsupialization involves opening the Bartholin cyst or abscess and then suturing the edges, thereby forming a permananent open pocket or pouch and allowing continued drainage. ^[13]  This procedure may be performed under general or local anesthesia, is more complicated than Word catheterization, and is typically reserved for recurrent cysts or abscesses. ^[14]

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

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. ^[5]  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. ^[15] 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. ^[15]

A randomized, controlled trial by Kroese et al found that 1-year recurrence rates were similar following treatment with a Word catheter or marsupialization for a Bartholin gland abscess or cyst. The study included 82 women who were treated with a Word catheter and 79 who underwent marsupialization. ^[16]

Note the following:

• Antibiotic treatment is at the discretion of the treating clinician. Antibiotics are not usually indicated in the immunocompetent patient with a drained Bartholin abscess. Antibiotics are typically administered if cellulitis is present.

• When a Word catheter is not available, and an urgent referral to a provider who can place the catheter is not possible, 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. ^[11] Marsupialization can also be considered in this setting. Gauze packing should be removed within 24-48 hours. ^[12]

• 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).

Bleeding

Excessive bleeding is a potential complication for any surgical procedure.

Recurrence

Recurrence is the most common complication after incision and drainage (~30%). Premature dislodgement of the Word catheter results in incision closure and high rates of recurrence.

Missed diagnosis of Bartholin duct carcinoma

Malignant tumors of the vulvar soft tissue are very uncommon. When localized in the Bartholin gland area, these tumors can be mistaken for benign lesions, leading to a delayed diagnosis. ^[17] 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. ^[18]

Progressive infection and sepsis

Patients with compromised immune systems may exhibit rare complications of progressive infection and sepsis. 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.

Other complications

In rare instances, Bartholin's abscesses can lead to complications such as maternal and fetal tachycardia, chorioamnionitis (E coli), and sternoclavicular septic arthritis. ^[19]