Bartholin Gland Diseases

Practice Essentials

The Bartholin glands are paired glands approximately 0.5 cm in diameter and are found in the labia minora in the 4- and 8-o’clock positions. Typically, they are nonpalpable. Each gland secretes mucus into a 2.5 cm duct. These two ducts emerge onto the vestibule at either side of the vaginal orifice, inferior to the hymen. Their function is to maintain the moisture of the vaginal mucosa's vestibular surface. This article focuses on the most common Bartholin gland diseases, cysts and abscesses (see the image below). Although rare, carcinoma of the gland should be considered in women with an atypical presentation. Primary carcinoma of the Bartholin gland accounts for approximately 5% of vulvar carcinomas.^{[1, 2, 3, 4, 5]}

Patients typically have an exquisitely tender, fluctuant labial mass with surrounding erythema and edema. Patients may have a painless, unilateral labial mass without signs of surrounding cellulitis. Bartholin abscesses are very rarely caused by sexually transmitted pathogens.

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. In one study, Word catheter treatment was successful in 26 of 30 cases (87%) of Bartholin cyst or abscess.^[6]  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.^{[7, 8]}

Medications used in the treatment of Bartholin abscesses include topical and local anesthetics. Antibiotics for empiric treatment of STDs are advisable in the doses usually used to treat gonococcal and chlamydial infections. Ideally, antibiotics should be started immediately prior to incision and drainage.

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Bartholin abscess. (Image courtesy of Dr. Gil Shlamovitz.)

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Pathophysiology

Bartholin glands are known to form cysts and abscesses in women of reproductive age. Cysts and abscesses are often clinically distinguishable. Bartholin cysts form when the ostium of the duct becomes obstructed, leading to distention of the gland or duct with fluid. Obstruction is usually secondary to nonspecific inflammation or trauma. The cyst is usually 1-3 cm in diameter and often asymptomatic, although larger cysts may be associated with pain and dyspareunia.^{[1, 2, 9, 10]}

Bartholin abscesses result from either primary gland infection or infected cyst. Patients with abscesses complain of acute, rapidly progressive vulvar pain. Studies have shown that these abscesses are usually polymicrobial and rarely attributable to sexually transmitted pathogens.

Adenocarcinoma of the Bartholin glands is rare, accounting for 1-2% of all vulvar malignancies. Typically, this lesion presents as a gradually enlarging gland in an asymptomatic, postmenopausal woman.^[3]

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Epidemiology

Approximately 2% of women of reproductive age will experience swelling of one or both Bartholin glands.^[11]

Bartholin gland diseases are rarely complicated by systemic infection, sepsis, and bleeding secondary to surgical treatment. Missed diagnosis of malignancy may result in poorer outcome for those patients.

These diseases typically occur in women between the ages of 20 and 30 years. Bartholin gland enlargement in patients older than 40 years is rare and should be referred to a gynecologist for possible biopsy.

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Prognosis

If abscesses are properly drained and reclosure is prevented, most abscesses have a good outcome.

Recurrence rates are generally reported to be less than 20%.

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Patient Education

For excellent patient education resources, visit eMedicineHealth's Skin, Hair, and Nails Center and Women's Health Center. Also, see eMedicineHealth's patient education article Bartholin Cyst.

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History

Patients with cysts may present with painless labial swelling. Abscesses may present spontaneously or after a painless cyst with the following symptoms:

• Acute, painful unilateral labial swelling
• Dyspareunia
• Pain with walking and sitting
• Sudden relief of pain followed by discharge (highly suggestive of spontaneous rupture)

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Physical

The following physical examination findings are seen in Bartholin abscess, as shown in the image below.

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Bartholin abscess. (Image courtesy of Dr. Gil Shlamovitz.)

See the list below:

• Patients typically have an exquisitely tender, fluctuant labial mass with surrounding erythema and edema.
• In some cases, areas of cellulitis surrounding the abscess may be present.
• Fever, though not typical in healthy patients, may occur.
• If the abscess has spontaneously ruptured, purulent discharge may be noted. If completely drained, no obvious mass may be observed.

The following physical examination findings are seen in Bartholin cysts:

• Patients may have a painless, unilateral labial mass without signs of surrounding cellulitis.
• If large, the cyst may be tender.
• Discharge from ruptured cyst should be nonpurulent.

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Causes

Uncomplicated Bartholin cysts are filled with nonpurulent mucous. Several studies have aimed to identify the most common bacterial pathogens responsible for Bartholin abscess formation. Studies from the 1970-1980s named Neisseria gonorrhoeae and Chlamydia trachomatis as common pathogens . More recent studies report the predominance of opportunistic bacteria such as Staphylococcus species, Streptococcus species, and, most commonly, Escherichia coli.^[7]

In a retrospective study by Kessous et al, a substantial percentage of patients with Bartholin gland abscess were culture-positive, with E coli being the single most common pathogen (43.7%), and 10 cases (7.9%) were polymicrobial. Culture-positive cases were significantly associated with fever, leukocytosis, and neutrophilia. Infection with E coli was significantly more common in recurrent infection than in primary infections (56.8% compared with 37%).^[12]

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Complications

The most common complication of treatment of Bartholin abscess is recurrence. Rare case reports exist of necrotizing fasciitis after abscess drainage.

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

Nonhealing wounds may occur. Bleeding, especially in patients with a coagulopathy, may be a complication.

Cosmetic scarring may result.

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Laboratory Studies

In otherwise healthy, afebrile adults, blood tests are not necessary to evaluate an uncomplicated abscess or cyst.

Sexually transmitted disease (STD) testing should be available at the request of the patient; however, Bartholin abscesses are very rarely caused by sexually transmitted pathogens.

Cultures are rarely useful in treatment of abscess; furthermore, routine culturing of drained fluid is not recommended.

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Procedures

The following features are suggestive of Bartholin gland malignancy. Patients who present with any of these features should be referred to a gynecologist for biopsy:

• Age older than 40 years
• Chronic or gradually progressive, painless mass
• Solid, nonfluctuant, painless mass
• Prior history of labial 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.^[7]

A Bartholin abscess is generally painful, and, thus, usually requires incision and drainage. Several techniques have been described,^[13] 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 Medscape Reference Clinical Procedures article Bartholin Abscess Drainage for Bartholin cyst management and further details.

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.^[14]

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.^[6] 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.^{[6, 11, 8]}

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

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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.^[15]

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.^{[11, 8]}

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

Recent studies have examined the safety and efficacy of carbon dioxide laser therapy as well as alcohol sclerotherapy to treat Bartholin abscesses.^{[16, 17, 18]} Early studies show promising results. In a recent study, the cure rate was nearly 96% with one laser treatment.^[19]

In another study of patients who received carbon dioxide laser therapy, the median operative time was 15 minutes (range, 12-35 minutes); median postoperative stay was 1 hour (range, 1-4 hours); and estimated 3-year relapse-free rate was 88.56%. Lesion wall thickness of 0.5-1.5 mm, multilocular lesions, and hyperechogenic lesions were correlated with recurrence.^[20]

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.^[13]

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Consultations

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

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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.

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Medication Summary

Medications used in the treatment of Bartholin abscesses include topical and local anesthetics. Antibiotics for empiric treatment of STDs are advisable in the doses usually used to treat gonococcal and chlamydial infections. Ideally, antibiotics should be started immediately prior to incision and drainage.

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Lidocaine anesthetic

• Dosing, Interactions, etc.

Clinical Context:  Decreases permeability to sodium ions in neuronal membranes. Inhibits depolarization, blocking the transmission of nerve impulses, which reduces pain.

Topical preparations are available in spray and ointment form.

Injectable lidocaine is available as 1% or 2% concentration, with or without epinephrine.

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Bupivacaine (Marcaine, Sensorcaine)

• Dosing, Interactions, etc.

Clinical Context:  By increasing electrical excitation threshold, slowing nerve impulse propagation, and reducing the action potential, bupivacaine prevents the generation and conduction of nerve impulses to reduce pain.

Concentrations of 0.25% and 0.5% are commonly used for local infiltration. Duration of action is significantly longer than lidocaine. Bupivacaine is available with or without epinephrine.

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Class Summary

These agents may be used topically or as injectables. Topical anesthetic may be used on vaginal mucosa prior to submucosal injection.

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Ceftriaxone (Rocephin)

• Dosing, Interactions, etc.

Clinical Context:  An effective monotherapy against N gonorrhoeae, ceftriaxone is a third-generation cephalosporin with broad-spectrum efficiency against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to 1 or more of penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.

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Ciprofloxacin (Cipro)

• Dosing, Interactions, etc.

Clinical Context:  An alternative monotherapy to ceftriaxone. Bactericidal antibiotic that inhibits bacterial DNA synthesis and, consequently, growth by inhibiting DNA-gyrase in susceptible organisms.

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Doxycycline (Bio-Tab, Doryx, Vibramycin)

• Dosing, Interactions, etc.

Clinical Context:  Inhibits protein synthesis and bacterial replication by binding with 30S and, possibly, 50S ribosomal subunits of susceptible bacteria. Indicated for C trachomatis.

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Azithromycin (Zithromax)

• Dosing, Interactions, etc.

Clinical Context:  Used to treat mild-to-moderate infections caused by susceptible strains of microorganisms. Alternative monotherapy for C trachomatis.

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Class Summary

Most Bartholin abscesses are caused by opportunistic pathogens. Uncomplicated abscesses in otherwise healthy women may not require antibiotic therapy after successful drainage. Treatment of N gonorrhoeae and C trachomatis should be initiated only in patients with confirmed disease.

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