Evaluation of treatments for Bartholin’s

cyst or abscess: a systematic review

BJG Illingworth 
 
K Stocking 
 
M Showell 
 
E Kirk 
 
JMN Duffy

First published:26 December 2019

 
https://doi.org/10.1111/1471-0528.16079

This article includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights16079

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Abstract
Background
No consensus on the management of symptomatic cysts or abscesses of the Bartholin’s gland exists.

Objectives
To assess the effectiveness and safety of surgical interventions for a symptomatic Bartholin’s cyst or
abscess.

Search Strategy
We searched bibliographical databases from inception to April 2019.

Selection Criteria
Randomised trials evaluating a surgical intervention for the treatment of a symptomatic Bartholin’s cyst
or abscess.

Data Collection and Analysis

Eight trials, reporting data from 699 women, were included. Study characteristics and methodological
quality were recorded for each trial. Summary estimates were calculated using random‐effects methods.

Main Results
When considering the recurrence of a symptomatic Bartholin’s cyst or abscess, the evidence was
consistent with notable effects in either direction (risk ratio [RR] 0.76; 95% confidence interval [CI] 0.41–
1.40) when comparing marsupialisation with incision, drainage and insertion of a Word catheter. Limited
inference could be made when comparing marsupialisation with incision, drainage and silver nitrate
insertion (RR 1.00; 95% CI 0.57–1.75), and incision, drainage and cavity closure (RR 0.25; 95% CI 0.01–
4.89). There was limited reporting of secondary outcomes, including haematoma, infectious morbidity
and persistent dyspareunia.

Conclusions
Current randomised trial evidence does not support the use of any single surgical intervention for the
treatment of a symptomatic cyst or abscess of the Bartholin’s gland.

Prospective Registration
PROSPERO: International Prospective Register of Systematic Reviews; CRD42018088553.

Tweetable Abstract
Further research is needed to identify an effective treatment for #Bartholin’s cyst or abscess.
@jamesmnduffy

Author-Provided Video
Evaluation of treatments for Bartholin’s cyst or abscess: a systematic
review
by Illingworth et al.

Introduction
Cysts and abscesses of the Bartholin’s gland are relatively common with a reported prevalence of
between two and three in 100 women.1 A cyst of the Bartholin’s gland can form when the ducts become
blocked due to trauma, mucus, or oedema secondary to infection.2 Abscesses may form due to
secondary infection of a cyst of the Bartholin’s gland or less commonly due to primary infection of the
Bartholin’s gland itself and are generally due to polymicrobial infection of the retained cystic fluid by
constituents of the vaginal flora, typically Escherichia coli or Staphylococcus sp.3 Malignancy of
Bartholin’s gland is characterised by a painless mass, which predominantly occurs in postmenopausal
women.4 Painful symptoms associated with a cyst or abscess of the Bartholin’s gland can interfere with
daily life. Without treatment, other serious morbidities can infrequently occur, including severe infection,
sepsis and rectovaginal fistula.5, 6

There is considerable uncertainty regarding the management of a symptomatic cyst or abscess of the
Bartholin’s gland. To our knowledge, there is no recent systematic review of the literature and no current
clinical practice guidelines to inform clinical practice. A previous systematic review has been
published.7 However, it was completed over 10 years ago, did not calculate summary estimates, and did
not follow the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement.8

We performed this systematic review to estimate the effectiveness and safety of surgical interventions
for the management of a symptomatic cyst or abscess of the Bartholin’s gland.

Methods
A protocol with explicitly defined objectives, criteria for study selection, approaches to assessing study
quality, primary and secondary outcomes, and statistical methods was developed. The protocol was
registered on PROSPERO: International Prospective Register of Systematic Reviews (CRD42018088553).
We followed the reporting guidelines for meta‐analyses and systematic reviews of randomised trials, as outlined by the
PRISMA statement.8 Women with lived experience of symptomatic cyst or abscess of the Bartholin’s
gland were not involved in this systematic review.

A comprehensive and systematic literature review was undertaken searching: (i) Cochrane Central
Register of Controlled Trials (CENTRAL), (ii) Cumulative Index to Nursing and Allied Health Literature
(CINAHL), (iii) Embase and (iv) MEDLINE from inception to April 2019. We searched the register using the
following MeSH headings: (i) Bartholin's gland; (ii) vestibular gland; (iii) randomised trial; (iv) controlled
clinical trial; and (v) clinical trials (see Supplementary material, Appendix S1).

Two review authors (BJGI and JMND) independently screened titles and abstracts. We critically reviewed
the full text of selected studies to assess eligibility. Any discrepancies between the reviewers were
resolved by discussion. We included randomised trials of patients with a diagnosis of a symptomatic
Bartholin’s cyst or abscess. We excluded pseudo‐randomised and non‐randomised studies.

Two review authors (BJGI and KS) independently extracted data by using a pilot‐tested data extraction form.
Information collected from each study included study design, setting, participants and outcomes. We extracted all relevant raw data
from each study. Two review authors (BJGI and JMND) independently assessed the methodological quality by
using the Jadad criteria.9

Unfortunately, no relevant core outcome set has been developed for the evaluation of potential
treatments for symptomatic cyst or abscess of the Bartholin’s gland.10 Data were extracted for the
primary outcome, recurrence of a symptomatic cyst or abscess of the Bartholin’s gland following
intervention, and for the following secondary outcomes: (i) duration of the procedure; (ii) duration of
inpatient stay; (iii) healing time; and (iv) adverse events. We actively contacted authors to seek
clarification and requested missing data or additional data to complete our analysis. Discrepancies
between the reviewers (BJGI and KS) were resolved through discussion, by contacting the authors, or by
consultation with a third reviewer (JMND).

REVIEW MANAGER 5.3 (Cochrane Collaboration, United Kingdom) was used to analyse results. We used
random‐effects models to calculate summary estimates. We present summary effects as a risk ratio (RR) with 95% confidence
intervals (95% CI). We intended to assess the presence of between‐study heterogeneity by using the I2 statistics.
If the I2 exceeded 50% we would have considered heterogeneity to be substantial. If we detected
substantial heterogeneity, we planned to take any statistical heterogeneity into account when
interpreting the results, especially when there was variation in the direction of effect. Intention‐to‐treat
analyses were carried out for binary outcomes. Continuous outcomes used the number of women receiving treatment.

The study received no funding.

Results
We discovered 254 records. After excluding 45 duplicate records, 209 titles and abstracts were screened.
Seventeen potentially relevant studies were evaluated. Eight randomised trials, reporting data from 699
women, met our inclusion criteria (Figure 1).11-18

Figure 1
Open in figure viewerPowerPoint
Flow of included studies.

Included randomised trials evaluated eight different interventions including

marsupialisation,11, 12, 15, 16, 18 incision, drainage and insertion of a Word catheter,13, 15 and
incision, drainage and silver nitrate insertion14, 17, 18 (Table 1). The included randomised trials were
relatively small, ranging from 22 to 212 women (median 44 women).14 Three randomised trials were
conducted in high‐income settings, including Denmark,11 the Netherlands,15 and the USA,13 whereas the
others were conducted in low‐ and middle‐income countries, including Jamaica12 and Turkey.14, 16-18 Two
randomised trials reported data from 70 women with an abscess of the Bartholin’s gland.11, 13 The
remaining six randomised trials reported data from 629 women with a symptomatic cyst or abscess of
the Bartholin’s gland. A single trial reported an objective diagnostic criterion: ‘A cyst or abscess was
defined as symptomatic if the patient asked for treatment for experienced pain or burden from swelling
with or without signs of inflammation at the 4‐ or 8‐o’clock position of the vulvar vestibule. The swelling had to be in
the Bartholin outflow tract, as confirmed by a gynaecologist.’15 The authors' judgements regarding the
methodological quality of the included studies are detailed in Table 1.

Table 1. Characteristics of included randomised trials

Study Country Participant Intervention 1 Intervention 2 Jadad

s
Criteria
n

Andersen Denmark 32 Incision, drainage and Marsupialisation 2

199211 cavity closure

Fletcher Jamaica 30 Marsupialisation I Marsupialisation I 1

199212 interrupted sutures continuous sutures

Gennis United 38 Incision, drainage and Incision, drainage and 2

200513 States insertion of a Jacobi insertion of a Word
ring catheter

Kafali 200414 Turkey 22 Aspiration and alcohol Incision, drainage and 2

sclerotherapy silver nitrate insertion

Kroese England 161 Incision, drainage and Marsupialisation 2

201715 insertion of a Word
The
catheter
Netherlands

Mathyk Turkey 154 Marsupialisation Total cyst excision 3

201816

Mungan Turkey 50 Incision, drainage and Total cyst excision 2

199517 silver nitrate insertion

Ozdegirmenci Turkey 212 Marsupialisation Incision, drainage and 3

200818 silver nitrate insertion

Marsupialisation compared with other treatments

Four trials, reporting data from 560 women, compared marsupialisation with a variety of other
treatments (see Supplementary material, Appendix S2).11, 15, 16, 18 Comparing marsupialisation with
incision, drainage and insertion of a Word catheter, the evidence was consistent with notable effects in
either direction (RR 0.76; 95% CI 0.41–1.40) (Figure 2). When comparing marsupialisation with incision,
drainage and insertion of a Word catheter, the evidence suggests that if the risk of recurrence is 23% in
the incision, drainage and insertion of a Word catheter group, then the risk in the marsupialisation group
would be 9.5–32.4%. These findings were not statistically significant.

Figure 2
Open in figure viewerPowerPoint
Recurrence of a symptomatic cyst or abscess of the Bartholin’s gland following surgical intervention.
Marsupialisation was also compared separately to incision, drainage and cavity closure (RR 0.25; 95% CI
0.01–4.89) and incision, drainage and silver nitrate insertion (RR 0.92; 95% CI 0.54–1.57). These results
suggest that if the risk of recurrence is 11.0% in the cavity closure group and 18.9% in the silver nitrate
insertion group, the risks with marsupialisation would be 0.1–54.3% and 10.8–33.0%, respectively.
Marsupialisation was also compared with total cyst excision in one trial (RR 11.00; 95% CI 0.62–195.56),
although, there were no reported recurrences in the total cyst excision group.

There did not appear to be a difference in duration of the procedure when comparing marsupialisation
with incision, drainag)e and cavity closure (mean difference [MD] 0.00 minutes, 95% CI −1.35 –
1.35 minutes); however, marsupialisation took less time to perform when compared with total cyst
excision (MD −5.48 minutes; 95% CI −7.31 to −3.65 minutes) (Table 2). There were no patients that
were reported to have failed to complete the procedure in the marsupialisation group when compared
with both incision, drainage and insertion of a Word catheter (RR 0.21, 95% CI 0.01–4.26) and silver
nitrate insertion (RR 0.10, 95% CI 0.01–1.85); therefore, the effect estimates remain imprecise. Reporting
of adverse effects was limited.

Table 2. Effect size estimates for primary and secondary outcomes

Outcomes and outcome Effect size P Trials Participants

measures estimate
number number

Marsupialisation compared with incision, drainage and Word Catheter insertion

Recurrence; yes/ no RR 0.76; 95% CI 0.41, 1.40 0.37 1 38

Failure to complete procedure; yes/ no RR 0.21; 95% CI 0.01, 4.26 0.31 1 38

Pain day one; VAS 1 to 10 MD −0.80; 95% CI −1.61, 0.05 1 38

0.01

Pain day three; VAS 1 to 10 MD −0.20; 95% CI −0.94, 0.60 1 38

0.54

Pain day seven; VAS 1 to 10 MD −0.20; 95% CI −0.85, 0.55 1 38

0.45

Marsupialisation compared with incision, drainage and cavity closure

Recurrence; yes/ no RR 0.25; 95% CI 0.01, 4.89 0.36 1 32

Duration of inpatient stay; days MD 2.00; 95% CI 0.84, 0.0008 1 32

3.16

Healing time, days MD 4.50; 95% CI 0.96, 0.01 1 32

8.04

Marsupialisation compared with incision, drainage and silver nitrate insertion

Recurrence; yes/ no RR 1.00; 95% CI 0.57, 1.75 1.00 1 212

Duration of procedure; minutes MD 0.00; 95% CI −1.35, 1.00 1 212

1.35
Outcomes and outcome Effect size P Trials Participants
measures estimate
number number

Failure to complete procedure; yes/ no RR 0.10; 95% CI 0.01, 1.85 0.12 1 212

Chemical burn; yes/ no RR 0.20; 95% CI 0.01, 4.12 0.30 1 212

Haematoma; yes/ no RR 0.14; 95% CI 0.01, 2.73 0.20 1 212

Febrile morbidly; yes/ no No events   1 212

Scar formation; yes/ no RR 1.68; 95% CI 1.21, 2.33 0.002 1 212

Persistent dyspareunia; yes/ no RR 1.75; 95% CI 0.53, 5.80 0.36 1 212

Marsupialisation compared with total cyst excision

Recurrence; yes/ no RR 11.00; 95% CI 0.62, 0.10 1 154

195.56

Duration of procedure; minutes MD −5.48; 95% CI −7.31, <0.0000 1 154

−3.65 1

Haematoma; yes/ no RR 3.00; 95% CI 0.32, 0.34 1 154

28.21

Scar formation; yes/ no RR 3.00; 95% CI 0.62, 0.17 1 154

14.40

Persistent dyspareunia; yes/ no RR 5.00; 95% CI 1.13, 0.03 1 154

22.07

Word catheter compared with Jacobi ring

Recurrence; yes/ no RR 1.92; 95% CI 0.13, 0.63 1 38

28.32

Operator satisfaction; yes/ no RR 0.80; 95% CI 0.59, 1.09 0.16 1 38

Patient satisfaction; yes/ no RR 0.54; 95% CI 0.29, 1.01 0.05 1 38

Incision, drainage and silver nitrate insertion compared with total cyst excision

Recurrence; yes/ no No events   1 50

Duration of procedure; minutes MD −13.50; 95% CI <0.0000 1 50

−15.50, −11.50 1

Healing time; days MD −4.60; 95% CI −5.47, <0.0000 1 50

−3.73 1

Chemical burn; yes/ no RR 3.00; 95% CI 0.13, 0.49 1 50

70.30

Haematoma; yes/ no RR 0.20; 95% CI 0.01, 3.97 0.29 1 50

Febrile morbidly; yes/ no RR 0.50; 95% CI 0.14, 1.78 0.28 1 50

 Outcomes and outcome Effect size P Trials Participants
measures estimate
number number

Scar formation; yes/ no RR 0.20; 95% CI 0.01, 3.97 0.29 1 50

Persistent dyspareunia; yes/ no RR 0.20; 95% CI 0.01, 3.97 0.29 1 50

Incision, drainage and silver nitrate insertion compared with aspiration and alcohol sclerotherapy injection

Recurrence; yes/ no RR 0.39; 95% CI 0.02, 8.73 0.56 1 22

Duration of procedure; minutes MD 8.00; 95% CI 5.82, <0.0000 1 22

10.18 1

Healing time; days MD 4.40; 95% CI 2.68, <0.0000 1 22

6.12 1

Scar formation; yes/ no RR 2.40; 95% CI 0.55, 0.24 1 22

10.49

Persistent dyspareunia; yes/ no No events   1 22

Incision, drainage and insertion of a Word catheter compared with incision,

drainage and insertion of a Jacobi ring
There was a single woman in each treatment group that had a recurrence of a symptomatic cyst or
abscess of the Bartholin’s gland when comparing incision, drainage and insertion of a Word catheter with
incision, drainage and insertion of a Jacobi Ring (RR 1.92, 95% CI 0.13–28.32), leading to imprecise effect
estimates.13 Patient satisfaction was compared between groups (RR 0.54, 95% CI 0.29–1.01),
suggesting that if patient satisfaction was 23% for the Jacobi ring, then it would be 6.6–22.9% in the
Word catheter group. No adverse events were reported.

Incision, drainage and silver nitrate insertion compared with other

treatments
Two trials, reporting data from 72 patients, compared incision, drainage and silver nitrate insertion with
both aspiration and alcohol sclerotherapy and total cyst excision.14, 17 Recurrence of a symptomatic
cyst or abscess of the Bartholin’s gland was compared between incision, drainage and silver nitrate
insertion and alcohol sclerotherapy (RR 0.39, 95% CI 0.02–8.73). With only one woman reporting
recurrence, we cannot interpret these results any further. In terms of the duration of the procedure,
incision, drainage and silver nitrate insertion were quicker to complete than Bartholin’s cyst excision (MD
−13.50 minutes, 95% CI −15.50 to −11.50 minutes), however, it took longer to complete than aspiration
and alcohol sclerotherapy (MD 8.00 minutes, 95% CI 5.82–10.18 minutes). The reported healing times for
incision, drainage and silver nitrate insertion were shorter than Bartholin’s cyst excision (MD −4.60 days,
95% CI −5.47 to −3.73 days) but longer than aspiration and alcohol sclerotherapy (MD 4.40 days, 95% CI
2.68–6.12 days). There were a few adverse events reported.

Discussion
Main findings
Current randomised trial evidence does not support the use of any single surgical intervention for the
treatment of a symptomatic cyst or abscess of the Bartholin’s gland. The estimates of differences in
recurrence rates between treatments were imprecise, and therefore, there is limited evidence about the
true treatment effect. Marsupialisation and incision, drainage and Word catheter insertion are
interventions that are commonly offered to women with a cyst or abscess of the Bartholin’s gland. Given
this, it is surprising that only a single trial has directly compared these interventions. This trial reported
evidence of notable effects in either direction; therefore, due to the lack of evidence, the effectiveness of
these common interventions remains unknown. The effectiveness of other interventions, including cavity
closure, alcohol sclerotherap and rubber ring catheter insertion, has been insufficiently evaluated within
a randomised trial setting. When considering key safety outcomes, there was limited reporting of patient‐
reported outcomes, persistent dyspareunia and adverse events.

Strengths and limitations

The strengths of this prospectively registered systematic review include its comprehensive search
strategy, methodological design and statistical analysis. All included studies reported the primary
outcome, recurrence of Bartholin’s cyst or abscess. The inclusion of a range of outcomes, including
patient‐reported outcomes and adverse events, ensured a more comprehensive evaluation of the different surgical interventions.

Systematic reviews are not without limitations. The comprehensive search strategy identified eight
randomised trials that often reported data from a relatively small number of women. Included trials
reported pooled data across women with both a symptomatic cyst and an abscess of the Bartholin’s
gland and we were unable to draw any conclusions regarding the effectiveness of individual
interventions within these distinctive patient populations. Pairwise meta‐analysis was not possible because no two
trials had compared similar interventions. To make indirect comparisons, network meta‐analysis could be considered for these data,
but because the included trials are small, of limited quality and of limited effectiveness, the additional
gain by using advanced statistics is not appropriate.

There was limited reporting of important adverse events, including haematoma, febrile morbidity and
persistent dyspareunia. When secondary outcomes were reported, there were often too few events to
make meaningful comparisons. Intention‐to‐treat analyses were used for the primary outcome and other binary outcomes.
Therefore, we assumed that all the women who withdrew from the study did not experience the event of interest.

Interpretation
Wechter et al.7 described an ideal treatment for a symptomatic cyst or abscess of the Bartholin’s gland
‘treatment should be fast and safe, performed as an outpatient under local anaesthetic, with uncommon
recurrence and rapid healing’. Evidence from current research unfortunately, fails to identify such a
treatment. In light of this uncertainty, pragmatic decisions regarding the most appropriate management
are based upon individual patient preferences, the availability of different treatment modalities, and
operator experience and expertise.

Given the evidence at hand, the authors in line with the conclusions made by Kroese et al., 15 recommend
incision, drainage and insertion of a Word catheter to be considered as the first‐line treatment for a
symptomatic cyst or abscess of the Bartholin’s gland. Although current evidence does not indicate differences in the
rates of recurrence of a symptomatic cyst or abscess of the Bartholin’s gland when compared with
marsupialisation, the insertion of a Word catheter offers other advantages, including the ability to
undertake the procedure within an office setting, the avoidance of general anaesthesia, and reductions
in resource utilisation such as hospital beds and usage of operating theatre time. Women should be
informed of the difference in pain intensity during the first postoperative day, with women reporting
increased pain intensity following Word catheter insertion when compared with marsupialisation.

Careful attention should be made to strategies that may reduce the risk of recurrence by ensuring that
operators are well trained, the cavity is completely evacuated, and antibiotics are tailored to
microbiology sensitivities; these approaches are known to reduce rates of recurrence and prevent
morbidity including postoperative sepsis.19, 20 Whatever treatment is offered, all women with a
symptomatic cyst or abscess of the Bartholin’s gland should be counselled regarding the high risk of
future recurrence. The recurrence rates reported within our review are consistent with the recurrence
rates reported in the published literature, which range from 2.7 to 17.4%.2, 7

Further research is needed. Commonly used interventions, including aspiration, alcohol sclerotherapy,
and Word or rubber ring catheter, could be considered as possible candidates for evaluation. In addition,
it would be prudent to invest resources in the development of novel interventions, including devices that
are smaller, less uncomfortable, and more likely to remain in place during the fistulisation process. Other
approaches could include the evaluation of earlier antimicrobial treatment of a symptomatic cyst or
abscess of the Bartholin’s gland, antimicrobial adjuvant therapy following surgical intervention, or the
development of new surgical techniques. Future antimicrobial treatment should consider differences in
the vaginal microbiome and likely pathogenic organisms based upon patient characteristics, including
ethnicity.

Conclusion
Current randomised trial evidence does not support the use of any single surgical intervention for the
treatment of a symptomatic cyst or abscess of the Bartholin’s gland. Although current evidence does not
indicate differences in the rates of recurrence of a symptomatic cyst or abscess of the Bartholin’s gland
when compared with marsupialisation, the insertion of a Word catheter offers other advantages,
including the ability to undertake the procedure within an office setting, the avoidance of general
anaesthesia, and reductions in resource utilisation such as hospital beds and usage of operating theatre
time. Further research is required to develop novel interventions, including devices that are smaller, less
uncomfortable and more likely to remain in place during the fistulisation process.

Disclosure of interests
The authors report no relevant conflicts of interests. Completed disclosure of interests forms are
available to view online as supporting information.

Author contributions
All authors contributed to the study design concept and design, acquisition of data, analysis and
interpretation of data, drafting of the manuscript, and critical revision of the manuscript for important
intellectual content.

Funding statement
The study received no funding.

Acknowledgements
We would like to thank Mr David J. Mills for administrative and material support.

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