Chapter 138. Bartholin Gland Abscess or Cyst Incision and Drainage

Bartholin gland cysts and abscesses are common problems for women of reproductive age, with an incidence of 2% in this population.1–3 A Bartholin gland and its duct may enlarge to form a Bartholin cyst or become infected and form a Bartholin abscess. A number of different techniques have been developed for the treatment of both cysts and abscesses.

The Bartholin glands are named after Caspar Bartholin, a Danish anatomist.1,4 They are located on each side of the vulvar vestibule beneath the fascia, posterolaterally to the vaginal orifice, and at the 4 and 8 o'clock positions.5,6 The glands are approximately 1 cm in diameter, the size of a pea, and drain through a duct approximately 2.5 cm in length. The ducts of the glands open into the vulvar vestibule at the 5 and 7 o'clock positions, existing between the hymenal ring and the labia minora. The cells of the gland produce mucin which is secreted during sexual excitement and contributes to vaginal lubrication.4,7 The Bartholin glands are not normally palpable. The gland has an extensive blood supply from branches of the internal pudendal artery. The neural supply is provided from branches of the pudendal nerve.

A cyst of the Bartholin gland may develop most often secondary to obstruction of the duct. This leads to ductal dilation and cyst formation. Noninfectious etiologies of cyst formation include inspissated gland secretions, trauma, tumor of the vulva, or scarring of the duct from repeated bouts of cyst formation.3 Cysts may grow as large as 1 to 3 cm. Bartholin cysts present as painless unilateral swellings in the labial area. A patient will become symptomatic if they become large enough or infected. Infected cysts contain purulent material and are known as a Bartholin's abscess; although it is more akin to a pseudoabscess unless the surrounding tissue appears erythematous, tender, and inflamed.3 A Bartholin cyst may present with pain, dyspareunia, pressure, difficulty with walking, or may be completely asymptomatic.4,7–11 The diagnosis is made on visual inspection of the vulva. Common signs are a mass near the inferior labia minora, drainage, and erythema.

Primary carcinoma of the Bartholin gland is a rare occurrence, but should be considered in the differential diagnosis. Most cancers occurring in the Bartholin gland are metastatic primary vulvar cancers. They can present as a Bartholin gland cyst when the vulvar cancer obstructs the ductal outflow of the gland. Adenocarcinoma (40%), squamous cell carcinoma (40%), adenoid cystic carcinoma (15%), and transitional cell carcinoma (5%) of the Bartholin gland have all been documented.6,12–15 Carcinoma can easily mimic a Bartholin gland cyst or abscess.

The majority of Bartholin gland cysts appear to be sterile or contain bacteria common to the vaginal flora.16 Studies of Bartholin gland abscesses have shown no bacterial growth in 7%, 10%, and 30% of specimens cultured.16–18 The causative organisms are multiple in the cultures that do grow bacteria. The most prevalent organisms isolated are anaerobes, with Bacteroides and Peptostreptococcus being the most common species.17 The remainder of the cultures demonstrated either aerobic/facultative isolates with Escherichia coli being the most common species or a mixture of both aerobic and anaerobic organisms. Neisseria gonorrhea and Chlamydia trachomatis have also been implicated as causative agents and have been isolated in 8% to 16% of cultures.16,19

Small and asymptomatic cysts in women less than 40 years of age can be managed expectantly. All others should be treated. Any cyst that becomes large and symptomatic (i.e., painful, interfering with physical or sexual activity) should be treated. Any cyst that appears tender, red, hot, or cellulitic represents a Bartholin abscess and requires treatment.

There is some controversy about the treatment of Bartholin cysts and abscesses in women over the age of 40. Previously, the recommendation was to excise the gland in women over the age of 40, for concern of the possibility of carcinoma. Carcinoma of the Bartholin gland is rare, comprising less than 1% of female genital tract neoplasms.11 It is felt that women over the age of 40 are at an increased risk for having carcinoma of the Bartholin gland, Bartholin duct, or adjacent structures; and thus all of these should be properly biopsied or completely excised and sent for pathologic evaluation.1,6,7,12–14 Another study reported an incidence of Bartholin gland cancer in postmenopausal women of 0.114 per 100,000 women and suggests that selective biopsy be performed to reduce the number of total excisions.15 Given the rarity of malignancies in this area, this view has been challenged in the recent literature. Currently, drainage and selective biopsy seems to be a reasonable alternative.7 In general, these women should be referred to a Gynecologist for diagnosis and further treatment.

Patients who have had multiple recurrences and previous treatments are best served with a referral to their Gynecologist for more definitive measures.

Consider draining Bartholin abscesses that are large or extremely tender in the Operating Room. Other indications for drainage in the Operating Room include patients with a contraindication to procedural sedation, those that cannot be adequately anesthetized using procedural sedation and local anesthetics, and those who cannot be safely sedated in the Emergency Department.

Simple Incision and Drainage

• Povidone iodine or chlorhexidine solution
• Gloves and gown
• Face mask with an eye shield or goggles
• Drapes
• Lidocaine, 1% to 2%
• 3 mL syringe
• 18 gauge needle
• 25 gauge needle
• 2 × 2 gauze squares
• 4 × 4 gauze squares
• #11 scalpel blade and scalpel handle
• Culture medium for routine bacteria, gonorrhea, and chlamydia
• Hemostat
• Small wick, 2 inches long

Incision and Insertion of a Word Catheter

• Equipment for simple incision and drainage
• Word catheter
• 5 mL sterile saline or water

Marsupialization

• Equipment for simple incision and drainage
• Two small retractors
• Specimen container for excised tissue
• Silver nitrate sticks or electrocautery
• Vicryl, 3-0 or 4-0 on cutting needle
• Scissors
• Small toothed forceps

Window Operation

• Same as equipment for marsupialization

Explain the risks, benefits, and potential complications of the procedure to the patient and/or their representative. The postprocedural care should also be discussed. Obtain a signed consent for the procedure. Some Emergency Physicians may omit the signed consent and place in the procedure note a statement saying: “the risks, benefits, and complications were described and discussed with the patient. They understood this and gave verbal consent for the procedure.”

Place the patient in the lithotomy position. Apply povidone iodine or chlorhexidine solution to the labia and allow it to dry. The surface of the vagina must be anesthetized as the procedure is extremely painful. The use of ice packs, topical refrigerant spray (Chapter 124), parenteral sedation, parenteral analgesics, or procedural sedation (Chapter 129) should be considered for patient comfort prior to infiltrating local anesthetic solution. Infiltrate 0.25 to 1.0 mL of local anesthetic solution subcutaneously under the mucosal surface of the labia minora for simple incision and drainage, with or without the use of a Word catheter. When injecting local anesthetics, ensure that you do not inject purulent material after aspiration as this can cause extensive inflammation. Infiltrate 2 to 3 mL of local anesthetic solution if a marsupialization will be performed.

The Emergency Physician should be wearing a gown, gloves, and a face mask with an eye shield or goggles. The cyst contents are usually under pressure and can spray out. A face mask and eye protection will prevent a mucous membrane exposure if the contents spray out of the incision. The gown will protect clothing from contamination.

A number of different treatments and procedures have been developed to manage a Bartholin cyst or abscess. These are largely influenced by its size, patient symptoms, the age of the patient, the suspected etiology, and any previous treatment in the same patient. The techniques include simple incision and drainage, incision and insertion of a Word catheter, marsupialization, a window operation, and complete excision.

Simple Incision and Drainage

The standard treatment for most abscesses is simple incision and drainage.7,9,10,20,21 Simple incision and drainage of a Bartholin cyst or abscess provides immediate pain relief but is often complicated by chronic recurrences. This technique is not recommended but described for the sake of completeness.

Spread open the labia to visualize the area (Figure 138-1). Make a 1 cm vertical incision on the mucosal surface of the labia minora in the vaginal vestibule. It should be parallel to the border of the hymenal ring, between the hymen and labia minora (Figure 138-1). The incision should ideally be external to the hymenal ring, if possible, and in the area where the duct normally exits. Extend the incision into the abscess/cyst cavity. Do not make incisions along the skin surface of the labia minora. Skin incisions can lead to the formation of a fistula tract, more postprocedural pain, and are fraught with complications. Culture the contents of the sac. Manually express the contents of the sac. Insert a hemostat and break any adhesions. Place a small wick within the cavity and exiting the incision to allow for complete drainage and prevent premature closure of the skin incision.

Incision and Insertion of a Word Catheter

Dr. B. Word first described this procedure in 1964.4 It is a relatively simple procedure that can be accomplished in the Emergency Department.4,7,9,10,22 The catheter is approximately 5 cm long and made of soft pliable latex with a 10 French tip. The tip contains a balloon that inflates up to a volume of 5 mL (Figure 138-2). These catheters cost approximately $15 each (Berkeley Medevices Inc., Berkeley, California).

Verify that the patient is not allergic to latex.8 Fill a 5 mL syringe armed with a 21 gauge needle with saline or water. Insert the needle into the self-sealing port on the distal end of the Word catheter. Inject 3 to 4 mL of the fluid to inflate the balloon. Observe the balloon for any leaks. If no leaks are visible, aspirate the fluid back into the syringe to deflate the balloon. Remove the needle from the self-sealing port.

Spread open the labia to completely visualize the area (Figure 138-3A). Make a 0.5 cm long puncture on the mucosal surface of the labia minora with a #11 scalpel blade into the cyst or abscess cavity (Figure 138-3A). This puncture should ideally be located just outside the hymenal ring and where the duct normally drains into the vaginal vestibule, between the hymen and labia majora at the 5 or 7 o'clock position. The incision should be just large enough to allow the passage of the Word catheter. Culture the contents of the sac. Manually express the contents of the sac. Insert a small hemostat and break any adhesions.

Insert the tip of the Word catheter deep within the cavity (Figure 138-3B). Inject 2 to 4 mL of sterile saline into the free end of the catheter to inflate the balloon (Figure 138-3C). Pain upon inflation of the balloon or persistent pain after the procedure indicates overinflation of the balloon. Do not use air to inflate the balloon. The catheter will stay in place because the inflated balloon is larger than the puncture incision. Tuck the free end of the catheter within the vaginal canal. The Word catheter should ideally stay in place for up to 4 weeks. This allows the tract to become epithelialized and prevent a recurrence. The patient should abstain from sexual activity while the catheter is in place.

Marsupialization

Marsupialization is an alternative treatment choice, initially described in 1950.1,7,9,10,21,23–25 It is performed once and is curative in some case series greater than 90% of patients.24,26 Advantages are that it can be done as an outpatient, is associated with little postoperative pain, has minimal postoperative scarring, and preserves the gland function.8 Marsupialization can be easily and safely performed in the Emergency Department using local anesthesia. Do not attempt to marsupialize a Bartholin abscess with an accompanying cellulitis. Some Obstetricians prefer to perform this procedure in the Operating Room under general anesthesia.

Make an oval-shaped or elliptical incision approximately 1.5 cm long and 1 cm wide through the vestibular mucosa over the cyst/abscess and just outside the hymenal ring (Figure 138-4A). Remove this piece of mucosa to visualize the anterior wall of the cyst/abscess cavity. Insert a retractor to pull the skin edges open and better visualize the sac (Figure 138-4B). Make a similar incision through the anterior wall of the cyst/abscess cavity (Figure 138-4B). Most times the initial incision will pierce both the vaginal mucosa and cyst wall. Remove this piece of tissue leaving the cavity exposed. Culture the contents of the sac. Express the contents of the sac. Insert a small hemostat and break any adhesions.

Control any bleeding with electrocautery, silver nitrate application, or manual pressure. Closing the cavity with interrupted sutures, as a final option, will control the bleeding. Suture closure is only temporary for hemostasis as this pocket will become reinfected and require another procedure. Remove any sutures placed in 20 to 30 minutes. Identify the former bleeding site and treat it with electrocautery or silver nitrate to prevent rebleeding after the patient leaves the Emergency Department.

Evert the cyst/abscess wall. Approximate the wall of the cyst/abscess to the vestibular mucosa. Sew the wall of the cavity to the mucosa of the vaginal vestibule with interrupted 3-0 or 4-0 Vicryl sutures (Figure 138-4C). The orifice will reduce in size, epithelialize, and form a new duct in time. Send all excised tissue to the Pathology Department to confirm the diagnosis and to rule out neoplasm.

Window Operation

This technique is almost identical to marsupialization.27 It differs only in the size of the incision. One study claimed that this procedure had no long-term complications or recurrences, thus making it a more desirable technique.27 However, the total patient population was small and the study has not been duplicated and republished. In essence, one follows the exact procedure for marsupialization with the exception of making a larger incision (2 to 3 cm long and 1.5 cm wide). At the completion of the procedure a wide opening is observed. The opening will be approximately one-half its original size at the 1 year follow-up. This much larger and radical incision is not recommended for the Emergency Physician.

Complete Excision

This technique is reserved for the treatment of recurrent cysts and abscesses unresponsive to less invasive techniques.7,9–12,15,21,27 It is also indicated in patients for whom carcinoma is suspected. Even though the function of the gland is to provide lubrication for sexual activity, in a well-estrogenized woman removal of the gland poses little clinical problem. In the past, excision of the Bartholin gland in all women over the age of 40 for fear of carcinoma was championed. This has been challenged given the low incidence of carcinoma of the Bartholin gland in favor of drainage and selective biopsy.7 Significant bleeding may complicate dissection into this area due to the underlying anastomosing venous plexus. If hemostasis is not achieved, a vulvar hematoma will result. Excision of the gland is often referred to as the “bloodiest little operation in gynecology.” This procedure should only be performed by a Gynecologist in the controlled setting of an Operating Room under general anesthesia.

An alternative to the Word catheter has been described in the literature.32,33 The advantages of this technique are that the materials are available in every Emergency Department, the device does not prematurely fall out as often happens with the Word catheter, and it is easily placed. Unfortunately, these reports had few patients. Larger studies comparing this technique to the Word catheter are required.

Prepare the equipment. Obtain a 5 to 7 cm long piece of tubing. Suggestions include cutting a piece from an 8 French T tube or a butterfly IV catheter.32,33 Insert a strand of 2-0 silk suture, without a needle or the needle cut off, through the tubing (Figure 138-5A).

The procedure is quite similar to that previously described. Make a stab incision in the lower half of the abscess and outside the hymenal ring with a #11 scalpel blade (Figure 138-5B). Insert a hemostat and break any loculations (Figure 138-5C). With the hemostat in the abscess cavity for support, make a second stab incision in the upper half of the abscess (Figure 138-5D). Insert one end of the silk suture into the incision and grasp it with the hemostat (Figure 138-5E). Pull the suture and tubing out through the lower incision (Figure 138-5F). Tie the ends of the suture to form a ring with the tubing (Figure 138-5G). Place four to five knots in the suture. Cut off the excess suture.

All abscess and cyst contents should be cultured. The initiation of antibiotics can be delayed pending the culture results, at the discretion of the physician. Administer antibiotics if the abscess is accompanied by cellulitis. Keep in mind the prevalence of MRSA in soft tissue infections and specifically in labial abscesses when choosing antibiotics.28,29

All patients should begin sitz baths in 2 days. Prescribe appropriate oral analgesics. Nonsteroidal anti-inflammatory drugs will provide most patients with adequate analgesia. Some patients may require a brief course (1 to 3 days) of narcotic analgesics. Give written discharge instructions to each patient explaining the aftercare, the complications, and the actions to take if a complication does arise. All patients should abstain from sexual activity until the inflammation and pain resolves or until the Word catheter is removed.

The most common complication with the incision and drainage technique is frequent recurrence. The most common complication of Word catheter insertion is premature loss of the catheter resulting in early incision closure and recurrence. It can also be associated with significant discomfort if the catheter is inserted improperly. Marsupialization has few complications and a low recurrence rate. With any of these procedures, one can miss a carcinoma of the Bartholin duct or Bartholin gland if a biopsy or excision is not performed. Bleeding and progressive infection, including sepsis and toxic shock syndrome, are rare but possible complications.30,31

The immunocompromised patient (e.g., diabetic, steroid dependent, or HIV positive) needs particular attention paid to cleanliness during and after the procedure. If the abscess is accompanied by cellulitis and/or involves the labia majora, consider inpatient management and gynecologic consultation. Initial IV antibiotics should cover MRSA. A large Bartholin/labial abscess in a diabetic patient requires close surveillance and a high suspicion for necrotizing fasciitis. Daily follow-up visits are recommended for these patients during the initial postprocedural period. Early hospitalization and administration of intravenous antibiotics are warranted if there is any sign of progressive infection.

Bartholin cysts and abscesses will be encountered by the Emergency Physician and can easily be treated. They present as a painful unilateral swelling of the inferior aspect of the labia. There are many treatments option. Culture all cyst or abscess contents. Send any tissue removed to the Pathology Department to rule out carcinoma. Refer patients with previously treated cysts or abscesses, those suspicious for carcinoma, and those over the age of 40 to a Gynecologist for definitive care. Give all patients written discharge instructions at the end of the procedure. All immunocompromised patients require very careful follow-up.