Information
Bartholin’s glands are located at the introitus and produce secretions that keep the vulva and vagina moist. Bartholin’s duct cysts are the most common cysts of the labia minora, occurring in about 2% of women. Abscesses are 3 times more common than cysts. Inflammation or trauma of the distal Bartholin’s duct may cause obstruction, resulting in retention of secretions, distension of the gland and formation of a Bartholin’s cyst. Infection of a Bartholin’s gland or cyst results in the development of an abscess.
Symptoms may include vulval/vaginal swelling, pain, pyrexia or dyspareunia.
Treatment options depend on:
- whether the patient is symptomatic or asymptomatic of the cyst
- whether it is a cyst or an abscess
- the size of the cyst/abscess.
A small, inactive, asymptomatic cyst can be managed conservatively with a warm bath or compresses to encourage drainage.
Patients with symptomatic cysts or abscesses should be offered the choice of conservative management, antibiotic therapy, the insertion of a Word Catheter under local anaesthesia or Marsupialisation under general anaesthesia. Surgical excision of the cyst is reserved for recurrent cysts only and is associated with significant risks such as excessive bleeding, vulval dryness and dyspareunia.
Who to refer:
Patients with symptomatic abscesses that have not responded to conservative management, antibiotic therapy, or are systemically unwell can be referred to the on-call gynaecology registrar at RIE or SJH via hospital switchboards.
Patients with small, inactive, asymptomatic cysts that are bothersome and haven’t resolved with conservative management can be referred for a routine gynaecology outpatient clinic via SCI gateway.
Bartholin’s cysts or abscesses are rare in postmenopausal women and differential diagnosis should be considered. Refer urgently to gynaecology if there are further red flag signs such as hard or irregular skin findings.
Once referred to secondary care the further options are:
Word Catheter
Patients requesting drainage of their Bartholins abscess or cyst should be offered a Word catheter. This 3cm long balloon-tipped silicone catheter has a diameter of a number 10 French Foley catheter and is inserted into the cavity of the abscess or cyst following drainage to avoid premature closure and re-accumulation. The recurrence rate associated with a Word catheter is similar to surgical marsupialisation.
The Word catheter is inserted under local anaesthetic as an outpatient in Gynaecology triage at RIE and on ward 12 in SJH.
The catheter is left in-situ for a maximum of 4 weeks. This allows re-epithelialisation of the Bartholin’s duct and on removal of the catheter the newly created duct will shrink and the gland will return to normal function. This does not impede normal daily activity or intercourse.
Most catheters will fall out prior to 28 days. However, the patient should contact Gynaecology Triage/ Ward 210 at RIE or ward 12 at SJH for medical review if:
- The catheter falls out ≤ 48 hours or
- The catheter falls out after 48 hours and the cyst or abscess has reformed
The patient will be followed-up by the gynaecology department between day 23-25 following insertion and an appointment will be arranged to remove it on day 28 if necessary.
Surgical Management
Marsupialisation of the Bartholin’s gland under general anaesthesia is the main surgical treatment used in the UK. This is associated with a 5 to 15% recurrence rate. There is a small risk of subsequent scarring, slow healing, haematoma, infection and dyspareunia.
Women who decline a Word catheter or who have other labial or vulval abscesses are offered marsupialisation over incision and drainage (which has a higher recurrence rate).
Surgical excision of the cyst is reserved for recurrent chronic cysts only and is associated with significant risks such as excessive bleeding, vulval dryness and dyspareunia.
First line management includes analgesia, warm bath or a compress to encourage drainage.
1. Spontaneous drainage
If the cyst or abscess has ruptured and pus is draining, take a swab for culture.
No further treatment or follow-up is required.
The patient should be advised to contact their GP if the abscess stops draining and reforms.
If there is obvious cellulitis, treat with antibiotics as described under Medical treatment.
2. Medical treatment
Broad spectrum antibiotics may be used if there is evidence of an abscess or cellulitis. It is most effective in the early stages of infection prior to the formation of a fluctuant collection of pus within the gland.
The predominant organism isolated are E. coli and anaerobes followed by S. aureus and Streptococcus agalactiae group B. The proportion of sexually transmitted diseases is declining but it still approximately 2%
1st Line Antibiotics
- Co-amoxiclav 625mg every eight hours orally for 5 days
Penicillin allergic patients
- Cotrimoxazole 960mg every twelve hours orally for five days
+ Metronidazole 400mg every eight hours orally for 5 days
Pregnant patients:
1st line:
- Amoxicillin 500mg every eight hours orally for five days
- + Metronidazole 400mg every eight hours for five days
Minor penicillin allergy
- Cephalexin 500mg every eight hours for five days
- + Metronidazole 400mg tds for 5 days
Severe penicillin allergy
- Call microbiologist for advice if history of anaphylaxis to penicillin
Cephalosporins and clindamycin can be associated with risk of developing C. difficile infection
If symptoms persist or worsen, refer to Gynaecology Triage/Ward 210 at RIE or Ward 12 at SJH via the gynaecology registrar on call.
Patient Information leaflet: NICE Interventional Procedure Guidance No323. Balloon catheter insertion for Bartholin’s cyst or abscess. December 2009
