Practice Essentials
The Bartholin glands are paired glands approximately 0.5 cm in diameter and are found in the labia minora in the 4- and 8-o’clock positions. Typically, they are nonpalpable. Each gland secretes mucus into a 2.5-cm duct. These 2 ducts emerge onto the vestibule at either side of the vaginal orifice, inferior to the hymen. Their function is to maintain the moisture of the vaginal mucosa's vestibular surface.
Bartholin gland cysts, abscesses, and masses may significantly affect a woman’s life. Pain and swelling can prevent sitting, walking, and intercourse. The diagnosis of Bartholin cysts and abscesses is often clinical. Atypical masses may require imaging (such as magnetic resonance), tissue biopsy, or complete excision. [1]
Bartholin gland cysts present as painless masses that are usually detected during a routine pelvic examination. Rarely, larger cysts may cause sexual discomfort or vulvar disfiguration. [1] Patients typically have an exquisitely tender, fluctuant labial mass with surrounding erythema and edema. Patients may have a painless, unilateral labial mass without signs of surrounding cellulitis. Bartholin abscesses are very rarely caused by sexually transmitted pathogens.
Diagnosis
Bartholin cyst abscesses do not frequently require laboratory or radiographic studies; however, wound culture and biopsy may be performed during incision and drainage of the abscess. If sexually transmitted infection is suspected, a sexually transmitted infection panel (including gonorrhea, chlamydia) should be considered and appropriate treatment initiated. A biopsy should be considered if malignancy is suspected because of atypical presentation of the mass or if the patient is older than 40 years. [2]
Although rare, carcinoma of the gland should be considered in women with an atypical presentation. Primary carcinoma of the Bartholin gland accounts for approximately 5% of vulvar carcinomas. [3, 4, 5, 6, 7] Its incidence is highest among women in their 60's. Atypical presentation should raise suspicion of a possible carcinoma. Malignant masses may also be fixed to underlying tissues. [1] Because published information on the diagnosis and treatment of Bartholin gland carcinoma is limited, this tumor is prone to misdiagnosis; most cases are found at an advanced stage and diagnosis is delayed. [8]
Smooth muscle tumors of the vulva are more difficult to diagnose and are frequently mistaken as Bartholin cysts prior to surgery. Labia majora leiomyoma at the site of the Bartholin gland is rather uncommon. Some cases can develop into atypical leiomyoma or even leiomyosarcoma with local tissue infiltration. If the clinical picture is unusual, it is better to send the patient for ultrasound and magnetic resonance imaging to exclude other causes; wide local surgical excision of the mass allows proper histopathologic and/or immunohistochemistry examination to differentiate between benign and malignant tumors. [9]
Kessous et al has described the most common microbial pathogens associated with Bartholin abscesses. Escherichia coli was the most common (43.6%), followed by Staphylococcus aureus (6.4%), group B streptococci (4.8%), and Enterococcus spp. (4.8%). Less than 10% of cases were polymicrobial in origin. E. coli–positive cultures were more common in recurrent infections (56.8%) than in primary infections (37%). Sexually transmitted infections were seldom causative, but testing for chlamydial and gonococcal infections remains important in susceptible patients. Broad-spectrum antibiotic coverage is advised in the absence of microbial sensitivities. [1]
Bartholin glands are generally nonpalpable when not obstructed. Cysts and abscesses are often found after onset of puberty, with decreased incidence after menopause. Both are difficult to differentiate on a physical exam. The cyst is usually 2-4 cm in diameter and may cause dyspareunia, urinary irritation, and vague pelvic pain. The cyst is usually filled with nonpurulent fluid that contains staphylococci, streptococci, and E. coli. [2]
Treatment
Excision of a Bartholin cyst or abscess may be required when office-based treatments fail. Possible complications include increased risk of bleeding, postsurgical infection, pain secondary to scar tissue, and complications from general anesthesia. Surgical removal of Bartholin glands has not been shown to interfere with sexual function. A specialist should perform this procedure. [1]
A Bartholin abscess is generally painful and therefore usually requires incision and drainage. In one study, Word catheter treatment was successful in 26 of 30 cases (87%) of Bartholin cyst or abscess. [10] Patients with an abscess often feel immediate pain relief after the drainage procedure; however, they may require oral analgesia for several days after the procedure. [11, 12]
A patient whose presentation is concerning for malignancy should receive close outpatient gynecologic follow-up for biopsy and possible excision. Those with an uncomplicated, asymptomatic cyst may be discharged with sitz bath instructions. Sitz baths (3 times daily) for several days may promote improvement with resolution or spontaneous rupture with resolution of the cyst.
Medications used in the treatment of Bartholin abscesses include topical and local anesthetics. Antibiotics for empiric treatment of STDs are advisable in the doses usually used to treat gonococcal and chlamydial infections. Ideally, antibiotics should be started immediately prior to incision and drainage.
A case report describing the use of nutraceutical supplements in the treatment of women with pelvic pain shows that clinical cases support clinical trial results showing the benefits of alpha-lipoic acid + palmitoylethanolamide + myrrh for management of gynecologic pelvic pain, allowing other analgesic, anti-inflammatory, and antineuropathic medications to be reduced or withdrawn. [13]
(See the image below.)
Pathophysiology
Bartholin glands are known to form cysts and abscesses in women of reproductive age. Cysts and abscesses are often clinically distinguishable. Bartholin cysts form when the ostium of the duct becomes obstructed, leading to distention of the gland or duct with fluid. Obstruction is usually secondary to nonspecific inflammation or trauma. The cyst is usually 1-3 cm in diameter and is often asymptomatic, although larger cysts may be associated with pain and dyspareunia. [3, 4, 14, 15]
Bartholin abscesses result from either primary gland infection or infected cyst. Patients with abscesses complain of acute, rapidly progressive vulvar pain. Studies have shown that these abscesses are usually polymicrobial and are rarely attributable to sexually transmitted pathogens. A retrospective cohort study found the incidence of Bartholin gland abscesses to be low (0.13%) during pregnancy. No significant difference was noted among pathogens found in culture-positive samples of pregnant and nonpregnant women. [1]
Adenocarcinoma and squamous cell carcinoma are the 2 most common histologic types of primary Bartholin gland carcinoma. Other, more rare types are transitional, adenoid-cystic, and undifferentiated carcinomas. Human papillomavirus (HPV) type 16 has been detected via polymerase chain reaction in squamous cell carcinoma. [1] Adenocarcinoma of the Bartholin glands is rare, accounting for 1-2% of all vulvar malignancies. Typically, this lesion presents as a gradually enlarging gland in an asymptomatic, postmenopausal woman. [5]
Etiology
Uncomplicated Bartholin cysts are filled with nonpurulent mucous. Several studies have aimed to identify the most common bacterial pathogens responsible for Bartholin abscess formation. Studies from the 1970-1980s named Neisseria gonorrhoeae and Chlamydia trachomatis as common pathogens. More recent studies report the predominance of opportunistic bacteria such as Staphylococcus species, Streptococcus species, and, most commonly, Escherichia coli. [11]
In a retrospective study, Kessous et al found that a substantial percentage of patients with Bartholin gland abscess were culture-positive, with E coli being the single most common pathogen (43.7%); 10 cases (7.9%) were polymicrobial. Culture-positive cases were significantly associated with fever, leukocytosis, and neutrophilia. Infection with E coli was significantly more common in recurrent infection than in primary infections (56.8% compared with 37%). [16]
Epidemiology
Approximately 2% of women of reproductive age will experience swelling of one or both Bartholin glands. [17]
Bartholin gland diseases are rarely complicated by systemic infection, sepsis, and bleeding secondary to surgical treatment. Missed diagnosis of malignancy may result in poorer outcome for those patients.
These diseases typically occur in women between the ages of 20 and 30 years. Bartholin gland enlargement in patients older than 40 years is rare and should be referred to a gynecologist for possible biopsy.
If abscesses are properly drained and reclosure is prevented, most abscesses have a good outcome. Recurrence rates are generally reported to be less than 20%.
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Word catheter. (Image courtesy of Dr. Gil Shlamovitz.)
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Word catheter with inflated balloon. (Image courtesy of Dr. Gil Shlamovitz.)
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Bartholin abscess. (Image courtesy of Dr. Gil Shlamovitz.)
