Bartholin Gland Diseases

Updated: Aug 10, 2017 

 Author: Antonia Quinn, DO; Chief Editor: Erik D Schraga, MD  more...
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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.
 Bartholin abscess. (Image
courtesy of Dr. Gil Shlamovitz.)
View Media Gallery

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]

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.
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%.

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.

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)

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

Bartholin abscess. (Image

courtesy of Dr. Gil Shlamovitz.)
View Media Gallery
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.

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]

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.

Differential Diagnoses
 Bartholin gland malignancy
  Chancroid in Emergency Medicine
 Emergent Management of Gonorrhea
 Endometriosis
 Gartner duct cyst
 Genital Warts
 Hematoma
 Hidradenoma
 Lipoma
 Sebaceous cysts
 Skene duct cyst
 Syphilis
 Vaginitis
 Vestibular mucous cysts
 Vulvar malignancy

Workup

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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.

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

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

View Media Gallery

Word catheter with inflated

balloon. (Image courtesy of Dr. Gil Shlamovitz.)

View Media Gallery

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]

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

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.

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.

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

Lidocaine anesthetic
 View full drug information
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.

Bupivacaine (Marcaine, Sensorcaine)

 View full drug information
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.

Antibiotics
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.

Ceftriaxone (Rocephin)
 View full drug information
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.

Ciprofloxacin (Cipro)
 View full drug information
An alternative monotherapy to ceftriaxone. Bactericidal antibiotic that
inhibits bacterial DNA synthesis and, consequently, growth by inhibiting
DNA-gyrase in susceptible organisms.

Doxycycline (Bio-Tab, Doryx, Vibramycin)

 View full drug information
Inhibits protein synthesis and bacterial replication by binding with 30S and,
possibly, 50S ribosomal subunits of susceptible bacteria. Indicated for C
trachomatis.

Azithromycin (Zithromax)
 View full drug information
Used to treat mild-to-moderate infections caused by susceptible strains of
microorganisms. Alternative monotherapy for C trachomatis.

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