Patients will present with a painful unilateral swelling in the vagina.
On examination, there will be a tender, erythematous swelling at 4 or 8 o’clock on the lateral vaginal wall. Tracking of the abscess along the vaginal wall may cause cellulitis.
Management of Bartholin’s cyst and abscess, Gynaecology (066)
Warning
Objectives
To provide guidance on the management of those presenting with and Bartholin’s cyst or abscess
Audience
All healthcare professionals involved in the care of women with a Bartholin’s cysts or abscess
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The Bartholin’s gland is a mucus secreting gland located bilaterally at the base of the labia minora, at the level of the hymen. When the duct becomes blocked, a cyst may form and the gland may be palpable. If the cyst becomes infected, an abscess may form which can cause severe pain. The life-time risk is approximately 3%.
A charcoal swab should be obtained from the cyst/abscess and sent for culture and sensitivity. It is estimated that >70% of cysts are culture sterile, and only 33% of abscess cultures are sterile.
Bartholin’s duct abscesses may be polymicrobial: E. coli (single most common pathogen), followed by infections including Staphylococcus aureus, Group B streptococci and Enterococci species. Neisseria gonorrohoea may be identified.
Additional appropriate swabs should be obtained for chlamydia and gonorrohoea if there is risk of a sexually transmitted infection.
Biopsy
A biopsy may be indicated in women over 40 years old as there is an increased risk of adenocarcinoma of the Bartholin’s gland.
This will depend on the severity and the duration of the patient’s symptoms in addition to patient preference.
Recurrence rates are not consistently reported. However, one RCT (WoMan trial) summarised that Marsupialisation and Word catheter recurrence at 12 months are similar (10-12%). Where incision and drainage or needle aspiration is performed, recurrence is thought to be higher, and therefore should be avoided if possible. The aim should being to create a new mucocutaneous junction between the wall of the cyst and the skin of the labia to allow continued drainage.
Conservative management, no signs of infection
Hot baths several times per day and simple analgesia. In the absence of cellulitis, antibiotics are not indicated.
Conservative management, no surgical intervention with suggestion of mild infection with presence of cellulitis or offensive discharge. A review of any previous swabs should be undertaken.
Where antibiotic treatment is required, suggested regimes are
Co-amoxiclav 625mg orally 8 hourly, total duration for 5 days
Or
Co-trimoxazole (Septrin) 960mg orally 12 hourly, total duration for 5 days (avoid 1st trimester pregnancy)
Surgical Management - Word Balloon Catheter
This treatment should be used first line in the surgical management of Bartholin’s cysts or abscesses. This is a very well tolerated procedure and has good operative success.
The Word catheter kits contain the 3cm long catheter, a syringe for inflation and the scalpel. A local anaesthetic, such as 1% lidocaine, may be used to infiltrate the skin prior to the initial incision being made. Via a 5mm stab incision into the mucosal surface of the labia minora, just exterior to the hymen ring, within the introitus in the region of the normal duct opening.
A charcoal swab should be obtained from the discharging fluid.
The catheter is inserted and inflated with a maximum of 3ml of saline, as per the manufacturer’s guidelines. If the balloon is overfilled this may cause extra discomfort so the balloon should be deflated by extracting some saline. If the incision is made too large the catheter may fall out so an anchor suture may be required to hold it in place.
The patient can go home with the catheter in situ and usually this stays in for 4 weeks to encourage formation of an epithelialised fistula and prevent refilling of the abscess. A patient information leaflet should be given with a contact number for the gynaecology emergency service.
After 4 weeks, the catheter is deflated and removed. If the catheter falls out at home during this time it may be left out provided the patient’s symptoms are resolving.
Where there are no signs of infection, antibiotic cover is not required.
Consideration should be made to cover with broad spectrum antibiotics if signs suggestive of an infection are present e.g. purulent offensive smelling discharge or signs of cellulitis. A review of any previous swab results should be undertaken.
Where antibiotic treatment is required suggest
Co-amoxiclav 625mg orally 8 hourly, total duration for 5 days
or
Co-trimoxazole (Septrin) 960mg orally 12 hourly, total duration for 5 days (avoid 1st trimester pregnancy)
Surgical Management - Marsupialisation
Where there is a recurrent abscess or if patient would prefer to avoid Word Catheter insertion, marsupialisation under a general anaesthetic should be performed. The purpose of this is to create a fistula and prevent further abscess formation. Packing is not routinely required.
In theatre, a single dose of intravenous antibiotic cover should be given.
1.2g of co-amoxiclav, IV
or
900mg of clindamycin, IV
Consideration should be made to continue cover with broad spectrum antibiotics, particularly if signs suggestive of an infection are present e.g. purulent offensive smelling discharge or signs of cellulitis.
Co-amoxiclav 625mg orally 8 hourly, total duration for 5 days
or
Co-trimoxazole (Septrin) 960mg orally 12 hourly, total duration for 5 days (avoid 1st trimester pregnancy)
This is not routinely required after marsupialisation of the cyst or abscess.
If patients have already been commenced on oral antibiotics, they may wish to complete the course. However, they do not routinely need to start treatment after the initial dose in theatre, if there are no signs suggestive of infection.
Simple vulval hygiene advice should include avoiding bubble baths, lotions or talcum powder. Sexual intercourse should be avoided until there is no pain or discharge.