What is a bartholin cyst
The Bartholin’s glands or greater vestibular glands, are a pair of pea-sized (rarely exceed 1 cm) exocrine glands, located at 4 O’ clock and 8 O’ clock position in the labia minora and drain through 2- to 2.5-cm–long ducts that empty into the vestibule (see Figures 1 and 2). They are not palpable except in the presence of disease or infection. They resemble salivary glands in structure. They are similar to Cowper’s glands in males. They secret colorless, mucoid discharge on sexual excitation which moisturizes the vestibule. During sexual stimulation, Bartholin’s glands release lubricant fluid 1). Bartholin’s glands begin to function at puberty 2).
The first person to describe this gland was Kaspar Bartholin, in 1977. This Dane became known for describing it along with the accessory ducts of the salivary and sublingual glands 3).
Bartholin cysts are common complications of the Bartholin’s gland, affecting the ductal region due to outlet blockage. When the Bartholin’s gland duct orifice becomes obstructed, the glands produce a build-up of mucus. This build-up leads to a cystic dilation of the duct and cyst formation. Infection of this cyst is likely to result in Bartholin’s gland abscess. Duct cyst is not required for the development of abscess 4). Bartholin’s abscess and cyst account for 2% of all gynaecological visits per annum in women at child-bearing age.
Bartholin’s abscesses are almost three times more common than Bartholin’s cysts 5). Bartholin’s abscess cultures often show polymicrobial infection. Large proportions of Bartholin’s gland abscess are bacterial culture positive with Escherichia coli being a common pathogen (Table 1). When determining antibacterial treatment options, it is essential to correlate the microbiological findings with their anti-biogram 6).
One case-control study 7) found that white and black women were more likely to develop Bartholin’s cysts or abscesses than Hispanic women, and that women of high parity were at lowest risk.
Bartholin’s gland abscess has been reported to have a recurrence up to 38% 8).
Bartholin’s gland abscess presents with a swelling in the vulva associated with pain and fever. On examination, an erythematous, localized, tender, soft, fluctuant swelling would be present in the labia minora. This is usually polymicrobial warranting broad-spectrum antibiotics 9). If not treated in time, it can rupture spontaneously but tends to recur 10).
Gradual involution of the Bartholin’s glands can occur by the time a woman reaches 30 years of age 11). This may account for the more frequent occurrence of Bartholin’s duct cysts and gland abscesses during the reproductive years, especially between 20 and 29 years of age.
The differential diagnosis includes hematoma, infected inguinal hernia or hydrocele of the canal of Nuck, infected lymphangioma, leiomyoma, lipoma, teratoma and sarcoma 12).
Because a vulvar mass in a postmenopausal woman can be cancer, excisional biopsy may be required. Some investigators 13) have suggested that surgical excision is unnecessary because of the low risk of Bartholin’s gland cancer (0.114 cancers per 100,000 woman-years). However, if the diagnosis of cancer is delayed, the prognosis can be poor.
Table 1. Bacteriology of Bartholin’s gland cyst and abscess
|Bacterial agents: aerobes||Bacterial agents: anaerobes|
|Brucella melitensis||Bacteroides species|
|Chlamydia trachomatis||Pasteurella bettii|
|Escherichia coli||Salmonella panama|
|Hypermucoviscous Klebsiella pneumonia||Clostridium perfringens|
|Neisseria gonorrhea||Peptostreptococcus species|
|Neisseria sicca||Fusobacterium species|
|Staphylococcus aureus: Panton-Valentine|
Lesions in the Bartholin’s gland can occur in the form of carcinomas, a rare type of gynecological tumor that accounts for 2-7% of vulvar carcinomas. This type of vulvar growth is carefully monitored among postmenopausal women who are more prone to Bartholin’s malignancy 16). The median age at which Bartholin’s gland cancer is diagnosed is 57 years old and carcinoma incidence is highest among women in their 60’s. The 2 common types, adenocarcinoma and squamous cell carcinoma, account for 80-90% of primary cases. The remaining 10-20% of cases include transitional, adenoid-cystic or undifferentiated carcinomas 17). Human papillomavirus is only related to squamous cell lesions. Benign tumors are rarer than carcinomas.
The Bartholin’s glands
The Bartholin’s glands, also called greater vestibular glands, are two pea-sized glands located at the posterior region of the vaginal opening. The glands have an oval shape with an average size of 0.5 cm and are located lateral to the bulbospongiosus muscle. The glands are homologous to the male bulbourethral or Cowper’s glands. The glands are connected to ducts, approximately 2.5 cm in width, situated between the labia minora and the hymenal edge. Through these ducts, the glands drain the mucus into the vaginal vestibule. The ducts open at the 4 and 8 o’clock position at the vaginal vestibule on each side of the vaginal opening. Embryologically, the Bartholin’s glands originate from the urogential sinus and therefore, utilize the external pudendal artery as a blood source. The gland is innervated by the pudendal nerve. The lymphatic drainage of Bartholin’s glands includes superficial inguinal and pelvic nodes.
Figure 1. Bartholin glands (greater vestibular glands)
Figure 2. Bartholin glands (greater vestibular glands)
Figure 3. Bartholin gland abscess (right Bartholin’s gland abscess)
Note: A linear scar of previous incision is seen.
Bartholin’s cyst complications
A Bartholin’s cyst or abscess may recur and again require treatment.
Bartholin cyst causes
Experts believe that the cause of a Bartholin’s cyst is a backup of fluid. Fluid may accumulate when the opening of the gland (duct) becomes obstructed, perhaps caused by infection or injury.
A Bartholin’s cyst can become infected, forming an abscess. A number of bacteria may cause the infection, including Escherichia coli (E. coli) and bacteria that cause sexually transmitted infections such as gonorrhea and chlamydia.
Bartholin cyst prevention
There’s no way to prevent a Bartholin’s cyst. However, practicing safe sex — in particular, using a condom — and maintaining good hygiene habits may help to prevent infection of a cyst and the formation of an abscess.
Bartholin cyst signs and symptoms
Bartholin’s cyst may be asymptomatic if Bartholin’s cyst is small and not inflamed. However, a small Bartholin’s cyst may be observed by physicians as a small mass in the region of the Bartholin’s gland. If the cyst grows, you might feel a lump or mass near your vaginal opening. Although a cyst is usually painless, it can be tender. A painless mass may be present without surrounding cellulitis, while abscesses commonly present with cellulitis and lymphangitis. Larger cysts and abscess tend to cause severe vulvar pain and swelling such that the patient experiences difficulty in walking, sitting and engaging in sexual intercourse (dyspareunia). During examination, an abscess presents as a tender mass in the lower vestibular region surrounded by erythema and edema. When the abscess grows large enough to extend to the upper labia, it may result in skin rupture and spontaneous drain 18). The patient may experience a sudden relief of pain after a discharge, highly suggesting presence of spontaneous rupture. Cysts can present in form of inguinal hernia 19).
A full-blown infection of a Bartholin’s cyst can occur in a matter of days. If the cyst becomes infected, you may experience:
- A tender, painful lump near the vaginal opening
- Discomfort while walking or sitting
- Pain during intercourse
A Bartholin’s cyst or abscess typically occurs on only one side of the vaginal opening.
In neonate, Bartholin’s duct cyst associated with hydrouretero-nephrosis and contralateral renal cyst can cause urinary retention 20). In the case of Bartholin’s gland cancer, painless mass is also present in the vulva-region. Mass fixated to the underlying tissue is often suspected for malignancy. First detection of sentinel node may lead to diagnosis of adenocarcinoma of Bartholin’s gland 21).
Diagnosis of Bartholin’s gland carcinoma is established upon histological examination. Women over the age of 40 are recommended to undergo drainage and biopsy to eliminate possible occurrence of carcinoma. Due to the rarity of Bartholin’s cancer, a biopsy is recommended over excision 22). In cases where Bartholin’s cancer is suspected, diagnostic criteria is as follows. The tumor must be primarily located in the labia, the surrounding skin must remain undamaged, and there must be at least a small amount of glandular epithelium present. When Bartholin gland carcinomas are present, metastatic disease is likely due to the vulva’s extensive vascular and lymphatic network 23).
Bartholin cyst diagnosis
To diagnose a Bartholin’s cyst, your doctor may:
- Ask questions about your medical history
- Perform a pelvic exam
- Take a sample of secretions from your vagina or cervix to test for a sexually transmitted infection
- Recommend a test of the mass (biopsy) to check for cancerous cells if you’re postmenopausal or over 40
If cancer is a concern, your doctor may refer you to a gynecologist who specializes in cancers of the female reproductive system.
Several labia and vaginal lesions can imitate Bartholin’s gland diseases. In such situations, differential diagnosis should be considered for the abscess or mass. Differential diagnosis include different types of cysts (inclusion, Gartner, Skene’s, sebaceous, vestibular mucosa, canal of Nuck), leiomyomas fibroma, hernia, hidradenoma, hematomas, lipomas, endometriosis, syringoma, accessory breast tissue, folliculitis, urethral diverticula, hidradenitis suppurativa, chancroid, gonorrhea, syphilis, vaginitis, warts or Bartholin’s gland cyst, abscess or cancer (Table 2) 24).
Table 2. Pathology of Bartholin’s Glands
|Cancer of Bartholin’s gland||adenoid cystic carcinoma|
|squamous cell carcinoma|
|Merkel cell carcinoma|
|transitional cell carcinoma|
|human papillomavirus type 16|
|small cell neuroendocrine|
|adenoma and adenomyoma|
|Abscess||cellular blue nevus|
Bartholin cyst treatment
Often a Bartholin’s cyst requires no treatment — especially if the cyst causes no signs or symptoms 26), but symptomatic Bartholin’s duct cysts and gland abscesses require drainage. Unless spontaneous rupture occurs, an abscess rarely resolves on its own. When needed, treatment depends on the size of the cyst, your discomfort level and whether it’s infected, which can result in an abscess.
Definitive drainage involves Word catheter placement for Bartholin’s duct cysts and gland abscesses, and marsupialization for duct cysts.
Treatment options your doctor may recommend include:
- Sitz baths. Soaking in a tub filled with a few inches of warm water (sitz bath) several times a day for three or four days may help a small, infected cyst to rupture and drain on its own.
- Surgical drainage. You may need surgery to drain a cyst that’s infected or very large. Drainage of a cyst can be done using local anesthesia or sedation. For the procedure, your doctor makes a small incision in the cyst, allows it to drain, and then places a small rubber tube (catheter) in the incision. The catheter stays in place for up to six weeks to keep the incision open and allow complete drainage. Although incision and drainage is a relatively quick and easy procedure that provides almost immediate relief to the patient, this approach should be discouraged because there is a tendency for the cyst or abscess to recur 27), 28). One investigator 29) reported a 13 percent failure rate for the procedure. Furthermore, incision and drainage may make later Word catheter placement or marsupialization difficult 30).
- Antibiotics. Your doctor may prescribe an antibiotic if your cyst is infected or if testing reveals that you have a sexually transmitted infection. But if the abscess is drained properly, you may not need antibiotics. Antibiotic therapies include Ceftriaxone, Ciprofloxacin, Doxycycline and Azithromycin. This treatment option should be restricted to women who have high risk of complicated infection such as recurrence, pregnancy, immunosuppression, MRSA risk, widespread surrounding cellulitis and gonorrhea or chlamydia infection. Topical or local anesthetics such as lidocaine and bupivacaine are also used to treat abscesses.
- Marsupialization of bartholin cyst. An alternative to Word catheter placement is marsupialization of a Bartholin’s cyst (Figure 6). This procedure should not be used when an abscess is present 31). Marsupialization can be performed in the office or if the cyst is deeply seated, in an outpatient surgical suite. Your doctor places stitches on each side of a drainage incision to create a permanent opening less than 1/4-inch (about 6-millimeter) long. An inserted catheter may be placed to promote drainage for a few days after the procedure and help prevent recurrence. Approximately 5 to 15 percent of Bartholin’s duct cysts recur after marsupialization 32). Complications associated with the procedure include dyspareunia (painful sex), hematoma, and infection 33).
A Word catheter is commonly used to treat Bartholin’s duct cysts and gland abscesses 34). The stem of this rubber catheter is 1 inch long and the diameter of a no. 10 French Foley catheter. The small, inflatable balloon tip of the Word catheter can hold about 3 mL of saline (Figure 4).
The inflated balloon allows the catheter to remain within the cavity of the cyst or abscess (Figure 5). The free end of the catheter can be placed in the vagina 35). To allow epithelialization of the surgically created tract, the Word catheter is left in place for four to six weeks 36), although epithelialization may occur as soon as three to four weeks 37).
Sitz baths taken two to three times daily may aid patient comfort and healing during the immediate postoperative period. Sex may be resumed after catheter insertion.
Unless there is evidence of cellulitis, antibiotic therapy is unnecessary. If cellulitis is present, cultures may be obtained, but the results rarely change management. Empiric broad-spectrum antibiotic therapy is started before culture results are available 38).
If a Bartholin’s cyst or abscess is too deep, Word catheter placement is impractical, and other options must be considered 39).
Figure 4. Word catheter
Figure 5. Word catheter insertion procedure
Figure 6. Marsupialization of Bartholin’s duct cyst
Note: (Left) A vertical incision is made over the center of the cyst to dissect it free of mucosa. (Right) The cyst wall is everted and approximated to the edge of the vestibular mucosa with interrupted sutures.
Rarely, for persistent cysts that aren’t effectively treated by the above procedures, your doctor may recommend surgery to remove the Bartholin’s gland. Surgical removal is usually done in a hospital under general anesthesia. Surgical removal of the gland carries a greater risk of bleeding or complications after the procedure.
Although Bartholin’s gland abscesses may rupture and drain spontaneously, recurrence is likely, and surgical excision may be necessary. Excision is not an office-based procedure.
Cultures for N. gonorrhoeae and C. trachomatis may be obtained. However, Bartholin’s gland abscesses tend to be polymicrobial, and empiric broad-spectrum antibiotic therapy should be used.
Excision of the Bartholin’s gland should be considered in patients who do not respond to conservative attempts to create a drainage tract, but the procedure should be performed when there is no active infection 40). If multiple attempts have been made to drain a cyst or an abscess, adhesions may be present, making excision difficult and resulting in postoperative scarring and chronic pain in the area 41).
Some investigators 42), 43) recommend excision of the Bartholin’s gland to exclude adenocarcinoma when cysts or abscesses occur in patients more than 40 years of age. Even though adenocarcinoma of the Bartholin’s gland is rare, gynecologic oncology referral should be considered for older patients with Bartholin’s duct cysts or gland abscesses.
Treatment of Bartholin’s carcinomas
Treatment of Bartholin’s carcinomas may vary between surgical methods, vulvectomy, or radiotherapy 44). Hyperbaric oxygen therapy following radical vulvectomy promotes wound healing 45). Primary adenoid cystic carcinoma is a rare malignancy of Bartholin’s cancer. Patients with the cancer can undergo adjuvant external beam radiation or hemivulvectomy 46). Early stage I of Bartholin’s carcinoma can be approached with lymphadenectomy 47).
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