Obstruction of the Bartholin duct producing a cyst, which may become infected to form an abscess.
Also known as: Bartholin cyst, Bartholin abscess, Bartholin duct cyst, vulvar abscess
Overview
The Bartholin (greater vestibular) glands lie at the 4 and 8 o'clock positions of the introitus and secrete mucus into the vestibule. Obstruction of the duct produces a Bartholin cyst; secondary infection produces an abscess.
Epidemiology
About 2% of women develop a Bartholin cyst or abscess in their lifetime, most commonly in reproductive years (20-30s). Postmenopausal masses warrant biopsy due to concern for Bartholin gland carcinoma (rare).
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Reproductive age (cysts and abscesses are rare in prepubertal and postmenopausal women)
Pathophysiology
Mucus accumulation behind the obstructed duct distends the duct into a cyst. Bacterial superinfection — typically polymicrobial (E. coli, anaerobes, streptococci) but historically often N. gonorrhoeae or C. trachomatis — produces an abscess.
Clinical presentation
Symptoms
Cyst: often asymptomatic; may cause discomfort with intercourse, walking, or sitting
Abscess: rapid onset of severe vulvar pain, often unable to sit or walk; may have fever
Spontaneous drainage of purulent material possible
Signs / physical exam
Cyst: nontender unilateral mass at the 4 or 8 o'clock position of the introitus, fluctuant
Bartholin gland carcinoma — Solid, fixed mass; postmenopausal patient — biopsy any new postmenopausal Bartholin mass
Inguinal hernia — Reducible, increases with Valsalva, located higher
Diagnostic workup
Diagnostic criteria
Clinical based on location and appearance.
Labs
Cultures or NAAT for GC and chlamydia from any drained abscess
MRSA prevalence rising — wound culture in significant or recurrent abscess
Imaging
Not routinely needed; biopsy any postmenopausal Bartholin mass
Diagnostic algorithm
Scenario
Recommended Management
Asymptomatic cyst, premenopausal
Observation, sitz baths
Symptomatic cyst or abscess
Word catheter placement x 4-6 wk
Recurrent cyst/abscess
Marsupialization or sclerotherapy
Postmenopausal mass
Biopsy/excise — rule out carcinoma
Severe cellulitis or immunocompromise
Add broad-spectrum antibiotics
Approach to Bartholin gland cyst and abscess by clinical scenario.
Treatment
First-line
Asymptomatic cyst in premenopausal patient: observation; warm sitz baths
Symptomatic cyst or abscess: drainage with a Word catheter — incision (intravaginal at mucocutaneous junction, 1.5 cm) with insertion of a 5 mL balloon catheter, left in place for 4-6 weeks to allow epithelialization of a new ostium
Sitz baths 2-3x daily after drainage
Antibiotics generally not required after adequate drainage in immunocompetent patients with localized abscess; treat with broad-spectrum antibiotics (e.g., trimethoprim-sulfamethoxazole + amoxicillin-clavulanate, or clindamycin) if surrounding cellulitis, immunocompromise, pregnancy, sepsis, or high-risk for MRSA
Treat any concurrent STI per CDC guidelines
Recurrent cyst/abscess
Marsupialization: incision with eversion of cyst wall sutured to vaginal epithelium, creating a permanent ostium
Silver nitrate ablation, alcohol sclerotherapy, CO2 laser are alternatives
Bartholin gland excision: reserved for refractory cases due to risk of bleeding and dyspareunia
Postmenopausal patient
Biopsy or excise — risk of underlying Bartholin gland carcinoma (squamous cell or adenocarcinoma)
Second-line / adjunct
Simple incision and drainage without Word catheter has high recurrence and is generally not recommended
Bartholin gland carcinoma in postmenopausal patient — high mortality if missed
Dyspareunia, scarring
PANCE pearls
Postmenopausal women with a new Bartholin mass require biopsy — Bartholin gland carcinoma is rare but easily missed.
Word catheter placement is the standard outpatient treatment for an abscess; simple I&D alone has unacceptably high recurrence.
Antibiotics are not routinely required after adequate drainage in healthy patients but are warranted with cellulitis, immunocompromise, or pregnancy.
Bilateral Bartholin lesions are rare — consider an alternative diagnosis.
Hidradenitis suppurativa often involves the vulva and can mimic recurrent Bartholin abscess; consider in any patient with multiple, recurrent vulvar abscesses, including axillary involvement.
References
ACOG — ACOG Clinical Update on Bartholin Gland Cysts and Abscesses
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