Bartholin Gland Cyst and Abscess
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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Risk factors
- Sexual activity, prior STI
- Local trauma (childbirth, episiotomy)
- 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
- Abscess: erythematous, warm, exquisitely tender, fluctuant mass; may demonstrate spontaneous drainage
Differential diagnosis
- Epidermal inclusion cyst — Smaller, more superficial, mobile; outside Bartholin location
- Skene gland cyst / abscess — Located periurethrally rather than at the introitus
- Vulvar abscess (folliculitis, hidradenitis suppurativa) — Multiple lesions, hair-bearing skin, recurrent in HS
- 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 |
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
Complications
- Recurrence (10-15% after Word catheter)
- Cellulitis, necrotizing fasciitis (rare, immunocompromised)
- 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
- CDC STI Guidelines 2021 — CDC Sexually Transmitted Infections Treatment Guidelines (MMWR 2021)
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