A woman complains of vulvar pain and swelling that has developed over the past 2-3 days, making walking and sitting very uncomfortable. On physical exam in the lithotomy position, there is a unilateral (occasionally bilateral), tender, fluctuant, erythematous swelling at 5 or 7 o'clock within the posterior labium minus.

What to do:

* If the swelling is mild without fluctuance (bartholinitis) or if the abscess is not pointing, the patient can be placed on an antibiotic (e.g., ciprofloxacin 500mg and azithromycin 1000mg po once, ofloxacin or doxycycline 100mg po bid x14d) and instructed to take warm sitz baths. Early followup should be provided.
* When the abscess is pointing, an incision should be made over the medial bulging surface and the pus evacuated.
* After drainage a Word catheter should be inserted through the incision. Inflate the tip of the catheter with sterile water to hold it in place and prevent premature closure of the opening.
* After drainage, the patient should be placed on antibiotics and instructed to take sitz baths.
* Provide for a followup exam within 48 hours.

What not to do:

* Do not mistake a nontender Bartholin duct cyst, which does not require immediate treatment, for an inflamed abscess.
* Do not mistake a more posterior perirectal abscess for a Bartholin abscess. The perirectal abscess requires a different treat ment approach.

Discussion
The most common organisms involved in the development of a Bartholin abscess are gonococci, streptococci, Escherichia coli, Proteus and Chlamydia, and often more than one organism is present. Bilateral infections are more commonly characteristic of gonorrhea. The Word catheter is a 5 mL balloon on a 5 cm catheter designed to retain itself in the abscess cavity for 4-6 weeks to help insure the development of a wide marsupialized opening for continued drainage, but they seldom stay in place that long. Iodoform or plain ribbon gauze can be inserted into the incised abscess as a substitute. If a wide opening persists, recurrent infections are not likely to occur, but they are common if the stoma closes.

What are Bartholin's glands and what do they do?

Bartholin's glands are a pair of small glands that are just next to the lower part of the entrance to the vagina. Each gland is about the size of a pea. Unless diseased or infected, you cannot normally see or feel these glands as they are within the soft tissues (labia) next to the entrance to the vagina.
Female genitals (234.gif)
Each gland makes a small amount of mucus-like fluid. The fluid from each gland drains down a short duct (tube) called the Bartholin's gland duct. Each duct is about 2 cm long and comes out towards the lower part of the entrance to the vagina. The fluid helps to keep the entrance to the vagina moist.

Bartholin's glands are named after Thomas Bartholin, the doctor who first described them in the 18th century. Bartholin's glands are sometimes called vestibular glands.
What problems can arise from Bartholin's glands?
Bartholin's cyst

If the duct that drains the fluid becomes blocked then a fluid-filled swelling develops (a cyst). The size of a cyst can vary from small and pea-like to the size of a golf ball, or even bigger in some cases. The cyst may remain the same size or may slowly become bigger. The reason why a Bartholin's duct may become blocked and lead to a cyst is not clear.
Bartholin's abscess

An abscess is a collection of pus (a thick fluid) that can occur with an infection. An abscess can occur in any part of the body, and sometimes occurs in a Bartholin's gland. Sometimes an abscess develops from a Bartholin's cyst that becomes infected. Sometimes the gland itself becomes infected which gets worse and forms into an abscess. Within a few days, the abscess can become the size of a hen's egg, sometimes larger, and is usually very painful.

Many types of bacteria (germs) can infect a Bartholin's cyst or gland to cause an abscess. Most are the common germs that cause skin or urine infections such as Staphylococcus and E. coli. So, any woman can develop a Bartholin's abscess. Some cases are due to sexually transmitted germs such as gonorrhoea or chlamydia.
Bartholin's gland cancer

This is a very rare cancer (about 1 in a million chance of a woman having it) and is very unlikely in women under 40. However, if there is any doubt about the cause of the swelling, a biopsy (small sample) can be checked.
Who gets Bartholin's cysts and abscesses?

About 1 in 50 women will develop a Bartholin's cyst or abscess at some point in their life. So, they are a common problem. Most cases occur 'out of the blue' in women aged between 20 and 30. However, they can occur in older or younger women.
What are the symptoms of Bartholin's cysts and abscesses?

A Bartholin's cyst or abscess typically only develops on one of the two glands.

If a cyst remains small and does not become infected, then you may have no symptoms. You may just feel a small lump to one side at the lower end of the entrance to the vagina which may cause no problems. However, a larger cyst may cause some discomfort, in particular, when walking, sitting, or having sex. Very large cysts can become quite painful.

With an abscess, a lump develops and quickly gets bigger, typically over a few hours or days. It is likely to become very painful. You may feel unwell and have a high temperature, and the skin over the abscess tends to become red, hot and very tender.
How is it diagnosed?

An examination by a doctor can usually diagnose the problem. A Bartholin's cyst and abscess have a typical appearance. No test is usually needed to make the diagnosis.
What is the treatment for Bartholin's cysts and abscesses?
Treatment is not always needed

If you have a small cyst that causes no symptoms, and does not become infected, then it may be best simply to leave it alone. However, always report a 'lump' in the area around your vagina (your vulva) to your doctor. Do not just assume a small lump is a Bartholin's cyst. It is best for a doctor to examine you to confirm the diagnosis and to rule out other causes of lumps in the vulva. If a cyst causes symptoms, then it can be treated.

A Bartholin's abscess will almost always need treatment as it can be very painful. However, if an abscess is left long enough it is likely to burst and then may resolve without treatment. This is not recommended though as it will be very painful and you could become quite ill.
Antibiotics for an infection or abscess

A course of antibiotics has a good chance of curing an infected gland or abscess. However, as a rule, the more pus that forms, the larger the abscess, and the less chance that antibiotics alone will be sufficient to clear the abscess without also needing to drain the pus.
A small operation is needed in many cases

The main aim of the operation is to drain any fluid or pus. This relieves symptoms. But also, another aim is to minimise the chance of the problem recurring.

Marsupialisation
A small operation called marsupialisation is the traditional treatment used to treat a Bartholin's cyst or abscess. It may be done under general anaesthetic. However, it can also be done under local anaesthetic when the overlying skin is numbed with an injection of local anaesthetic. A small cut (incision) is made into the cyst or abscess just inside the entrance to the vagina. Any fluid or pus drains out. The cut is widened to about 1 cm. A few stitches are then used to to stitch the inside lining of the cyst to the overlying skin. This then creates a small new permanent opening for fluid to drain out of the gland.

Initially, the opening that is left is like a pouch - hence the name of the operation. However, the opening gradually becomes smaller and soon the opening becomes tiny and not noticeable. But this new opening is, in effect, like a new duct which allows any fluid that is made by the gland to drain.

A course of antibiotics may be prescribed if pus is drained from an abscess. However, antibiotics are not always needed once the pus has been drained.

Marsupialisation is usually successful. In only a few cases does the problem recur if this procedure is done. If a simple cut is made to drain the fluid or pus without then doing a marsupialisation, there is a higher chance that the problem will recur at some point.

As with all operations there is a small chance of problems. For example, infection of the wound occurs in a small number of cases following marsupialisation.

Other types of operation
In recent years, various other procedures have been introduced which are sometimes used instead of marsupialisation. For example:

* A variation of the traditional operation where the fluid or pus is drained, but then the cyst or cavity wall is stitched together.
* Insertion of a Word catheter. This is a small, thin rubber tube. The head of the catheter is inserted through a small cut made into the cyst or abscess. The tip of the catheter has a tiny balloon which is blown up to keep the catheter in place for 2-6 weeks. Whilst the catheter is in place you can go about your normal activities. The aim is to keep the opening from closing up. As the tissues heal, it allows the cells to form a new 'duct' over the catheter.
* Insertion of a Jacobi ring. This too is a thin catheter that is passed into the cyst or abscess through one small cut and out from a separate cut. The two ends of the catheter are tied together with a silk thread that goes through the middle of the catheter. As with a Word catheter, this is left in place for a few weeks to allow a new 'duct' to form.

The operation chosen depends on factors such as the size of the cyst or abscess, and the preference and expertise of the surgeon. They all seem to work well with a low rate of recurrence.
Other techniques

Some people recommend that sitting in a warm bath for 10-20 minutes, three or four times a day, may encourage a Bartholin's cyst to burst naturally. It is not clear how well this may work. However, it is always best to see a doctor if you think an abscess is developing.

Other less commonly used procedures include application of silver nitrate to an abscess cavity, and use of a carbon dioxide laser.

Sometimes the entire gland is removed by a surgical operation. This is considered a 'last resort' but may be advised if you have several recurrences of a Bartholin's cyst or abscess.
Will it happen again?

In most cases, a Bartholin's cyst of abscess does not recur after treatment with one of the operations described above, or if antibiotics alone cured the problem. However, they do recur in some cases when treatment needs to be repeated.
Cases due to sexually transmitted infections

If you have a Bartholin's gland infection or abscess, a swab of the area or a sample of pus is usually sent to the lab to identify which germ caused the infection. If a sexually transmitted germ is the cause of the infection, then further screening for other sexually transmitted infections for yourself and your partner will usually be advised.
Can Bartholin's cysts or abscesses be prevented?

Not usually. Most occur 'out of the blue' for no apparent reason. Some Bartholin's abscesses are due to sexually transmitted infections, and so using a condom when having sex may prevent some cases. As mentioned, some people say that, if a cyst develops, then sitting in warm baths may possibly help it to burst and prevent a possible abscess from developing.

References

* Patil S, Sultan AH, Thakar R; Bartholin's cysts and abscesses. J Obstet Gynaecol. 2007 Apr;27(3):241-5.
* Schecter JC, Hipp A; Bartholin Gland Diseases. eMedicine, December 2009.
* Omole F, et al, Management of Bartholin's Duct Cyst and Gland Abscess. American Family Physician July 1, 2003
* DA Hil and JJ Lense, Office Management of Bartholin Gland Cysts and Abscesses, American Family Physician, April 1998
* Shlamovitz GZ; Bartholin Abscess, Drainage. eMedicine, May 2009.; Excellent explanation - with illustration/media - of procedures
* Gennis P, Li SF, Provataris J, et al; Jacobi ring catheter treatment of Bartholin's abscesses. Am J Emerg Med. 2005 May;23(3):414-5.
* Haider Z, Condous G, Kirk E, et al; The simple outpatient management of Bartholin's abscess using the Word catheter: a preliminary study. Aust N Z J Obstet Gynaecol. 2007 Apr;47(2):137-40. [abstract]
* Balloon catheter insertion for Bartholin's cyst or abscess, NICE Interventional Procedure Guideline (December 2009)


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