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Bartholin's Cyst

Bartholin's Gland Cyst

A Bartholin's cyst is formed secondary to occlusion of the duct that excretes the fluid from the gland. 


Presentation

Normally, women with Bartholin’s cyst have painless and swollen labia. Abscesses may occur spontaneously or subsequent to occurrence of a painless cyst. The symptoms being described include dyspareunia, acute and painful one-sided labial swelling, discomfort associated with walking and sitting [9], and an abrupt pain relief followed by discharge, indicative of spontaneous rupture.

On physical examination of individuals with Bartholin’s cyst, a unilateral painless labial mass is visible without signs of surrounding cellulitis, which is tender to touch (especially if the cyst is large), and non-purulent discharge from a ruptured cyst.

Food Poisoning
  • poisoning Streptococcus pneumoniae – responsible for pneumococcal infections , such as infections of the inner ear or sinuses Haemophilus influenzae – responsible for a number of infections such as epiglottitis , an infection of the epiglottis (the flap[your.md]
Vulvar Pain
  • Abscesses cause severe vulvar pain and sometimes fever; they are tender and typically erythematous. A vaginal discharge may be present. Sexually transmitted diseases may coexist.[merckmanuals.com]
  • Symptoms Vulvar Pain worse with walking and intercourse VI. Signs Firm swelling at posterior vaginal introitus Occurs at 5:00 and 7:00 positions (where Bartholin Gland ducts exit) Posterior labia minora affected VII.[fpnotebook.com]

Workup

Blood testing for assessment of uncomplicated cyst or abscess in healthy individuals is not required. Abscesses secondary to sexual transmitted pathogens are very unusual. However, tests for sexually transmitted diseases must be obtainable upon the request of patients with Bartholin's abscesses. Management by means of cultures is seldom beneficial to patients with abscesses [10]. In addition, routine culturing of drained fluids is not supported.

Patients presenting a chronic or gradually progressive, painless mass, solid non-fluctuant painless mass, >40 years of age, and with prior history of labial malignancy are at risk for Bartholin's gland malignancy.

Treatment

Women may self-manage asymptomatic cysts using sitz bath or soak in a few inches of warm water in a tub. Soaking can be performed 3-4 times a day for about 10-15 minutes. Following days of treatment, cysts occasionally disappear. However, if treatment fails, the patient should consult a doctor.

Treatment is optional in women with symptomatic cysts with age below 40 years of age. Since cysts commonly recur, draining of these cysts is usually useless. Consequently, surgery by means creating a permanent opening from the gland’s duct to the surface may be performed. This allows draining of fluid when cyst is refilled.

The following procedures can be performed following administration of local anesthesia:

Placement of a catheter: A small incision is made to allow insertion of the catheter into the cyst [9]. The balloon is inflated once the catheter is positioned. In order for permanent opening to take place, the catheter is left there for about 4 to 6 weeks. Women can function normally and perform their usual activities while the catheter is in place; yet, sexual activity may cause discomfort.

The following are reminders and steps in placement of Word catheter:

  • Distinguish the spot for catheter placement (outside and parallel to the hymen ring).
  • Examine the balloon of the Word catheter using a 2-4ml sterile saline solution and observe any leakage before catheter placement.
  • Wash the site using a surgical soap, for instance, a povidone-iodine solution.
  • Administer local anesthesia (i.e. lidocaine 1%).
  • Create a small stab incision using a scalpel blade into the cyst cavity. In order to prevent the catheter from falling out, the stab incision must be no more than 3-4mm.
  • After draining of fluids, the Word catheter should be introduced into the cyst cavity.
  • Fill up the balloon using a 2-4ml sterile saline solution.
  • To prevent the balloon from leaking or deflating, tie a suture around the catheter.
  • Tuck the catheter end into the vagina.

Marsupialization: The procedure is performed in outpatient operating room. A small cut into the cyst is made and the inside edges of the cyst are stitched to the surface of the vulva. General anesthesia is necessary on occasion [11] [12].

Women may experience having a discharge for weeks following these medical procedures. Normally, the use of party liners is required. Performing sitz baths for a number of times per day may speed up healing and alleviate the pain. Excision may be an option if cysts recur.

Treatment of woman aged 40 or beyond can be managed by:

  • Surgical excision of the entire cyst
  • Sample tissue testing of the cyst to assess whether cancerous or not, followed by marsupializing the cyst

Treatment for abscesses may include:

  • Oral antibiotics for 1 weeks
  • Insertion of catheter for draining of abscess, or primarily begin with marsupialization to treat the abscess or later to avoid refilling.

Cysts tend to recur regardless of the treatments used.

Prognosis

About 85 percent of patients who receive treatment, regardless of treatment techniques performed, demonstrate favorable outcomes as evidenced by elimination of pain and inflammation and the appearance of unrestrained draining duct. Meanwhile, recurring cysts or abscesses can be more challenging to treat. Vaginal dryness and dyspareunia may be experienced following surgical removal of the gland.

Etiology

Obstruction of the duct into the vestibule generally leads to formation of Bartholin's cyst in the duct system of the Bartholin's gland. These glands are responsible in lubrication during sexual activity and provide moisture on the vulval surfaces. While it is believed that the formation of the cyst is secondary to occlusion of the ducts, the contributory factor for the occlusion itself is usually unclear. The obstruction may be secondary to edema compressing the duct, trauma, or from infection [3] [4]. The size of the cyst is determined by the amount of gland secretions collected. There is rapidly increased growth of the cyst with sexual activity, but it shrinks or becomes stable with decreased sexual activity. There is increased likelihood for another cyst from prior partial or unfinished treatment of previous Bartholin's cyst. Scarring and constriction of the duct opening may occur from prior treatment.

It is more common that a polymicrobial nongonorrheal infection, rather than a primary infection affecting the gland or duct, may cause development of a Bartholin's abscess. One suggested entry mechanism is the transmission of infection in an ascending manner trough a small stenotic opening trough which release of thick Bartholin's gland mucous secretion is not possible. Even though cultures may demonstrate no growth or presence of a sterile abscess, infections have a propensity to be polymicrobial with facultative, anaerobic, and aerobic members of the vaginal flora. There is low incidence of occurrence of Bartholin's cyst or formation of abscess following trauma or medical procedure such as episiotomy or vulvovaginal surgery.

The types of bacteria isolated from Bartholin's gland abscess are as follows [5]:

Epidemiology

Bartholin's cyst or abscess may occur in 2 percent of women population at some point in their lives [6]. The presence of abscesses is about three folds more common than cysts.

By the time a female reaches the age of 30, gradual involution of Bartholin’s glands takes place [7]. This may predispose to more likelihood of development of Bartholin’s cysts and abscesses during the reproductive years, particularly between ages 20 and 29.

Excisional biopsy is an option when vulvular mass is present in postmenopausal woman as this may be suggestive of a cancer. As the risk for Bartholin's gland cancer is low (0.114 cancers per 100,000 woman-years), researchers proposed that surgical removal of the gland is unnecessary. However, prognosis can be poor if diagnosis of a malignancy is delayed.

Sex distribution
Age distribution

Pathophysiology

During the reproductive age of women, Bartholin's cysts and abscesses are known to develop frequently. Obstruction of ostium of the duct causes distention of the gland or duct which leads to formation of the cyst. In general, the obstruction can be due to trauma or nonspecific inflammation. Cyst rarely causes symptoms, although pain and dyspareunia may be present with larger cysts [8].

Primary gland infection or cyst infection may result to Bartholin's abscess. Patients may complain of vulvular pain described as acute and rapidly progressive pain. Research has demonstrated that abscesses are usually caused by different types of microorganisms and infrequently related to sexually transmitted pathogens.

Cancer of the Bartholin's glands is uncommon and accounts for 1-2% of all the vulvar malignancies. The lesion usually manifests as slowly progressive increasing gland in an asymptomatic, postmenopausal woman.

Prevention

The Bartholin’s cyst cannot be prevented, although practicing safe sex must be observed. For an instance, the use of contraceptive, such as condom, and maintaining good hygiene habits may reduce the risk to cyst infection as well as development of abscesses.

Summary

The Bartholin's glands, also known as greater vestibular glands, originate from the epithelial buds on the dorsal surface of the vestibules. Their primary location is at the labia minora, they drain through ducts (2 to 2.5cm in length) and empty into the vestibule directed at 4 o’clock and 8 o’clock positions [1]. The glands are small and very seldom exceed 1cm. These are not appreciated during palpation but possible in the presence of infection or disease.

Bartholin's glands share the same structure as the Cowper's glands (also known as bulbourethral glands) in males [2]. The glands provide moisture for the vestibules which start to function at puberty.

The openings of the glands may become blocked causing the fluid to backflow into the gland. This gives rise to a swollen but painless sac called a Bartholin's cyst. When the fluid inside the cyst becomes infected, an abscess may develop. Formation of Bartholin's cyst or abscess is relatively common. The size and severity of the cyst and the presence of infection influence treatment options.

Often, home remedies are sufficient to manage the cyst. In some situations, invasive technique and surgery is needed to drain the Bartholin's cyst. Antibiotics may be beneficial in the presence of infection.

Patient Information

A cyst can be characterized as a liquid-filled sac or a semi-solid material that develops underneath the skin or just within the body. Bartholin’s glands are two small glands located on each side of the labia minora, outside the vaginal opening. During sexual activity, a lubricating fluid is released by these glands. When the gland is blocked, formation of the so called Bartholin’s cyst occurs. Blockage of the gland may happen due to swelling, infection, or chronic irritation.

The formation of Bartholin’s cyst happens when the duct that exits the glands becomes occluded. This results to accumulation of fluids produced by the glands and then causes the glands to swell and thus form a cyst. When infected, abscesses occur.

Several bacteria may give rise to Bartholin's abscesses. These include bacterial organisms which are linked to sexually transmitted disease (STD) (e.g. gonorrhea and chlamydia) and bacteria found in the gastrointestinal tract (e.g. Escherichia coli). 

Generally, patients with Bartholin’s cyst are asymptomatic. However, larger cysts may cause pain when walking, sitting, or during sexual activity. A painless lump is noticeable in women just near the vaginal opening, and a lop-sided vulva.

Woman should consult a doctor when cyst continues to grow or persist after days of treatment, including immersion in warm water in a tub. Other reasons that suggest the need for physician office visit include painful cyst (often suggestive of abscess), fever, cyst interfering with sitting or walking, and age over 40.

Doctors usually detect the presence of a cyst during pelvic examination. They can also distinguish upon presentation whether it is infected or not. They may send samples of discharge to examine for other infections, such as STD. In the presence of abscess, doctors may culture the fluid. They also perform biopsy of a cyst for a differential diagnosis as vulvar cancer often resembles a cyst. In general, biopsy is done when the woman is older than 40 or the cyst is irregular or bumpy in form.

Women in their below 40’s do not require treatment of asymptomatic cysts. Sitz baths may help resolve mild symptoms (if present). Surgery may be recommended in symptomatic cysts as well as abscesses. The goal of surgery is to create a permanent opening from the duct to the exterior as cysts often recur even after simple drainage. Catheter insertion can be done to stimulate fibrosis and produce permanent opening. Marsupialization is another option. This procedure involves suturing of the everted edges of the cyst to the exterior.

If the cyst recurs, removal of the cyst is recommended. For women on their past 40’s of age, all cysts should be explored, biopsied, or removed.

Treatment of abscesses consists of oral antibiotics which include MRSA (e.g., trimethoprim 160 mg/sulfamethoxazole 800 mg bid or amoxicillin/clavulanate 875 mg po bid for 1 week) and clindamycin (300 mg po qid for 1 week).

References

Article

  1. Hill DA, Lense JJ. Office management of Bartholin gland cysts and abscesses. Am Fam Physician. 1998; 57:1611–6.1619–20.
  2. Stenchever MA. Comprehensive gynecology. 4th ed. St. Louis: Mosby. 2001; 482–6,645–6.
  3. Marzano DA, Haefner HK. The Bartholin gland cyst: past, present, and future. J Low Genit Tract Dis. 2004; 8:195-204.
  4. Lynch PJ, Edwards L. Genital dermatology. New York, NY: Churchill Livingstone; 1994; 140-142.
  5. Lee YH, Rankin JS, Alpert S, et al. Microbiological investigation of Bartholin's gland abscesses and cysts. Am J Obstet Gynecol. 1977; 129:150-153.
  6. Kaufman RH. Benign diseases of the vulva and vagina. 4th ed. St Louis: Mosby. 1994; 168–248.
  7. Stillman FH, Muto MG. The vulva. In: Ryan KJ, Berkowitz RS, Barbieri RL, eds. Kistner's Gynecology: principles and practice. 6th ed. St. Louis: Mosby. 1995; 66–8.
  8. Berger MB, Betschart C, Khandwala N, et al. Incidental Bartholin gland cysts identified on pelvic magnetic resonance imaging. Obstet Gynecol. 2012; 120:798-802.
  9. Haider J, Condous G, Kirk E, et al. The simple outpatient management of Bartholin's abscess using the Word catheter: a preliminary study. Aust N Z J Obstet Gynaecol. 2007; 47:137-140.
  10. Scott PM. Draining a cyst or abscess in a Bartholin's gland with a Word catheter. JAAPA. 2003; 16:51-52.
  11. Davis GD. Management of Bartholin duct cysts with the carbon dioxide laser. Obstet Gynecol. 1985; 65:279-280.
  12. Jacobson P. Marsupialization of vulvovaginal (Bartholin) cysts: report of 140 patients with 152 cysts. Am J Obstet Gynecol. 1960; 79:73-78.

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Last updated: 2018-06-22 08:55