Bartholin Cyst and Abscess
There are two Bartholin glands, located on
each side of the vaginal opening at the level of the posterior
fourchette, or at about the 4 o’clock and 8 o’clock position. Each
gland is about the size of a pea. Normally, they are neither visible
These glands produce small amounts of
secretions from their cuboidal epithelial lining that are not
clinically significant. The secretions do not contribute meaningfully
to sexual lubrication and their physiologic purpose, if any, is not
known. Only when they become diseased do they become clinically
The secretions produced by Bartholin glands pass
through a 2 to 3 centimeter, somewhat convoluted duct before reaching the skin
surface. If a duct becomes obstructed (for example, from trauma, swelling, or
infection), then the normal outflow of gland secretions may become blocked. The
secretions will then gradually build up beneath the skin surface, and this
collection of secretions is called a Bartholin cyst. Since the normal production
of secretions is very modest, the development of a cyst is a slow process.
Bartholin cysts are first noticed as painless
swellings in the labia majora. The patient may or may not be aware of it
although usually they are aware. Bartholin cysts are not dangerous, have no
malignant potential, and may be safely observed, if that is the patient's
desire. They can be confused with other cysts in the vulvovaginal area,
Vaginal inclusion cyst
Gartner duct cyst
Bartholin cysts may also be confused with:
Other masses in the vulvar area that can
mimic Bartholin cysts include:
Accessory breast tissue
Should the Bartholin gland become
infected, it will form a Bartholin abscess. In this case, the labia
majora becomes excruciatingly painful, red and swollen. Some of these
will drain spontaneously and this process may be hastened by warm
moist dressings or sitz baths. Others will require drainage.
It is a relatively simple procedure to drain Bartholin cysts or
Incision and Drainage of the abscess gives
immediate relief. Watch this video for a demonstration of this procedure on a
Select a place for the incision. It should
be on the medial side of the cyst, relatively close to the hymeneal
ring, although if there is one area of obvious thinning of the
epithelium, I’d aim for the thinnest part, so long as it still medial
and in the mucous membrane.
Give local anesthetic of 1% Lidocaine over
the incision site.
Steady the cyst or abscess with one hand
while directing a scalpel into the center of the abscess.
Culture purulent drainage for gonorrhea
and chlamyia. Only infrequently will these cultures be positive, but
often enough to warrant your attention. Other commonly cultured
organisms include coliforms and strep.
If loculations are present within the
abscess cavity, break them up by inserting and then spreading a
Antibiotic therapy is optional but usually
used, particularly if the patient is febrile, the abscess large, or
the skin is red or tender.
Simple incision and drainage of the
abscess will provide immediate relief and more likely than not,
permanent cure. In a significant minority of patients treated with
simple I&D, the abscess or cyst will re-occur. This happens because
after healing, the surgical opening into the cyst or abscess cavity
seals over, resulting in isolation of the Bartholin gland beneath the
skin. For this reason, more aggressive surgical treatment is sometimes
Packing the abscess cavity with gauze and leaving a
wick external to the cavity is not an effective technique with Bartholin cysts
and abscesses. Early in my surgical career, I used this method a number of times
and never had the packing remain in the cavity for more than a few hours.
One commonly used, good technique to keep
the drainage tract open is the insertion of a "Word Catheter." A Word
catheter is a soft rubber tube with an inflatable tip. After drainage
is established, insert the tip of the Word catheter into the cavity
and inflate the balloon tip with a few cc of any physiologic liquid
such as sterile saline or lidocaine. The inflated balloon tip will
keep the catheter from becoming dislodged and the stalk of the
catheter will help keep the drainage tract open long enough for the
cut skin edges to re-epithelialize to the inside of the cyst.
Essentially, this results in a new duct connecting the Bartholin gland
directly to the skin surface.
The stalk of the catheter is bent back and
inserted into the vagina, so it can be left in place for many days.
Ideally, it should be left for a few weeks, but it is irritating
enough to the patient that it may need to be removed after several
days. Even this short period of time is enough for it to be effective.
Even with the Word catheter, there may still be recurrences of the
cyst or abscess, but they are less frequent than with the simple I&D
Another way to accomplish the creation of a new
drainage tract is to "marsupialize" the cyst or abscess. After opening the cyst,
suture the squamous epithelial skin edge to the cuboidal epithelial cyst wall.
This allows the cut skin cell fibroblasts the opportunity to spread down into
the cyst, with creation of a new opening, allowing secretions to escape.
Other techniques, less well tested, include
sclerosing the cyst cavity with silver nitrate, alcohol, or laser. Surgical
tubing and IUDs have been used to maintain drainage. Good results have been
reported in limited numbers of cases with each of these methods.
Finally, complete excision of the Bartholin gland is
an option when other, simpler procedures have been unsuccessful. Excision should
result in permanent cure, but it is technically challenging as the tissue planes
may be scarred from old infection, bleeding may be surprisingly brisk, and
healing more painful and protracted than you might think. In the end, the
results are usually good.
Bartholin gland cancer is an uncommon malignancy,
comprising about 5% of all vulvar cancers. It may be either adenocarcinoma or
squamous cell carcinoma, since there are both glandular and duct epithelium
present in the Bartholin gland.
Bartholin cancer is found about once in
every 1 million women years. It’s usually discovered after
unsuccessful treatment for a presumed Bartholin cyst or abscess.
Treatment is radical vulvectomy and lymph node dissection. Because
this malignancy is usually discovered only after multiple drainage
procedures have failed, some gynecologists recommend excision of all
Bartholin cysts or abscesses in women over age 40, when the risk of
Bartholin gland cancer begins to rise.
Others disagree, observing that you would
have to do hundreds of excisions of benign but annoying Bartholin
cysts…with significant surgical morbidity…in order to somewhat improve
the survival rate of the one individual with Bartholin cancer. These
other voices recommend excision among women over age 40 only in