Etiology

Bartholin cysts arise in the duct system of the Bartholin gland and are typically the result of occlusion of the main duct into the vestibule. The glands are believed to provide a lubricating function during intercourse and a moisturizing effect on the vulval surfaces.

While ductal obstruction is an essential etiologic factor, the cause of obstruction is typically obscure.[6] It may occur secondary to mucus or trauma, or from infection and edema compressing the duct.[12]

The size of the cyst depends on accumulation of gland secretions and is exemplified by rapid enlargement during sexual activity and shrinkage or stability of cyst size in women with diminished sexual activity. It is typically identified when the cyst is 1 to 4 cm in diameter.

Previous Bartholin cyst increases the risk of another cyst, especially if prior treatment was incomplete. Prior treatment may cause scarring and stenosis of the duct opening.

A Bartholin abscess more commonly results from polymicrobial infection of the cyst fluid, rather than primary infection of the gland or duct. One proposed entry mechanism is ascending infection through a stenotic opening that is too small to allow emission of thick Bartholin gland mucous secretion.[6] While cultures may reveal no growth or presence of a "sterile abscess," infections tend to be polymicrobial with anaerobic, facultative, and aerobic members of the vaginal flora.[1][13][14] One study involving 219 women found that 38.2% of Bartholin gland abscesses were sterile, while 61.8% were culture-positive, with Escherichia coli being the single most common pathogen, followed by polymicrobial infections, Staphylococcus aureus, group B streptococci, and Enterococcus species. Three cases of extended-spectrum beta-lactamase-producing E coli strains were identified.[15] Rarely, Bartholin cyst or abscess occurs after episiotomy, trauma, or vulvovaginal surgery. Common isolates from Bartholin gland abscesses include:[13][14]

  • Staphylococcus aureus

  • Staphylococcus epidermidis

  • Streptococcus faecalis

  • Group B streptococci

  • Enterococcus species

  • Escherichia coli

  • Pseudomonas aeruginosa

  • Bacteroides fragilis

  • Clostridium perfringens

  • Peptostreptococcus species

  • Fusobacterium species

  • Coliforms

  • Neisseria gonorrhoeae

  • Chlamydia trachomatis.

Pathophysiology

The paired Bartholin glands are situated deep in the perineal compartment between the deep and superficial fascia of the urogenital diaphragm and immediately posterior to the vestibular bulbs.[16] The ducts course through loose connective tissue of the superficial compartment to exit on the vestibule distal to the hymen at the 5 and 7 o'clock positions.[10][12]

A diagnosis of Bartholin cyst is made on clinical appearance, but the distinction between cyst of the duct and cyst of the gland can only be made on histopathology and is primarily of theoretical rather than clinical concern. The duct is lined by transitional epithelium, whereas the lining of the gland acinus is a single layer of columnar or cuboidal epithelium.[10]

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