Approach

Treatment can be conservative or surgical, and the choice depends on symptoms, age of the patient, and whether infection is present.[1][21] Small, asymptomatic cysts may not require any treatment beyond conservative management.[6][19] Larger cysts are more likely to be symptomatic and therefore more often require surgical intervention. The aims of surgical management are to preserve glandular function and to prevent recurrence of disease.[22]

None of the treatment options are contraindicated in pregnant women, but the increase in pelvic blood flow during pregnancy may lead to excessive bleeding with surgical treatment.[19] Unless the cyst obstructs the vagina (soft tissue dystocia), surgery should be delayed until after delivery in pregnant women.

Asymptomatic

A small, quiescent, asymptomatic Bartholin cyst should be left alone and managed with sitz baths or warm compresses to aid drainage.[23] No further treatment is usually required in women <40 years of age.[2][6][19] Over age 40 years, the possibility of malignancy must be considered and biopsy may be indicated, but simple asymptomatic cysts can be managed in the same way once malignancy has been excluded.

Symptomatic

Various surgical modalities have been proposed for symptomatic cysts and are aimed at creating a new ductal ostium to allow continuous drainage, or destruction of the cyst wall lining.[1] The overall success rate of surgery (marked by the absence of swelling and discomfort, and the appearance of a freely draining duct) is 87% to as high as 96% at 1 year regardless of the method used.[18] One 2020 systematic review found no clear consensus on the single best surgical intervention.[24]

Any procedure that preserves function and prevents the formation of an abscess is preferable to excision of the gland.[6] Morbidity associated with surgical excision of Bartholin cysts is more frequent than is generally recognized and includes cellulitis, recurrence, intraoperative and postoperative hemorrhage, hematoma, and painful scar tissue.[6]

In the absence of cellulitis, antibiotic therapy is unnecessary.[1][18] More than 70% of cultures from Bartholin cysts and about 33% of cultures from Bartholin abscesses are sterile.[13][14]

If cellulitis is present, broad-spectrum antibiotics are recommended, as infection is often polymicrobial.[13][14][15] Diabetic patients with cellulitis need careful observation, as they are susceptible to necrotizing infection. Admission to the hospital should be considered.

Marsupialization[25]

  • The objectives of marsupialization are to construct a new mucocutaneous junction between the wall of the cyst and the skin of the labia, and to place it in approximately the normal position.[10][26] This allows for patency of the gland to be maintained so that secretory function is not lost. The same operation with slight variations can be done regardless of whether the cyst is infected, ruptured, or recurrent.[12][26] However, if infection is accompanied by marked inflammation and necrosis, sutures will pull through and marsupialization will not be possible. Marsupialization can be performed under pudendal nerve block or local anesthetic and is the preferred treatment for many clinicians.[10][12]

    [Figure caption and citation for the preceding image starts]: Marsupialization of a Bartholin cyst. The site is cleaned and anesthetized, and then a 1.5 to 2 cm incision is made just distal to the hymen ring within the introitus into the region of the normal duct opening. The cyst/abscess cavity is irrigated and loculations are broken down if necessary. The incised cyst/abscess wall is then approximated to the edge of the vestibular skin.From the personal collection of Colleen Kennedy Stockdale; used with permission [Citation ends].com.bmj.content.model.Caption@1d9c8d8f

  • If the initial sutures pull through, a larger suture may be tried. If the larger suture also pulls through, further attempts should not be made. The aperture should be as large as possible, ideally large enough to admit 2 fingers, as it will shrink to half its size within 1 to 3 weeks.[6][10][26] Twice-daily sitz baths are recommended postoperatively.

  • Variations on this technique have been described, including use of carbon dioxide laser to create a hemostatic cyst defect without use of suture, packing with an iodoform gauze that is removed after 1 week, using rubber drains after placing a linear incision into the cyst cavity, or removing an oval-shaped section of tissue (the window technique).[12][25][27][28][29] Possible advantages of the window technique include a reduction in recurrence rate.[12][22] One small study found that use of a carbon dioxide laser was associated with a more favorable sexual health recovery than surgical incision.[30] The use of iodine to identify the optimal site of incision for anatomic placement of the ostium has also been described.[31]

  • Complications of marsupialization include moderate pain, hematoma formation, prolonged healing, and dyspareunia due to scarring.[1][18] The recurrence rate is between 2% and 25%.[1][12]

Catheter drainage

  • The Word catheter is a safe, simple, and effective outpatient treatment and is a reasonable alternative to marsupialization.[17] The incision for the catheter should be made with a number 11 scalpel blade and placed just exterior to the hymen ring within the introitus in the region of the normal duct opening. If the cyst is too deep, placing the catheter is difficult and may not be possible. Clinical use is limited by availability and its tendency to dislodge.[32] The catheter is the size of a 10F Foley catheter with a 2 to 3 cm stem. A sealed stopper is attached at one end and a 5 mL capacity latex inflatable balloon at the other.[6] The catheter should be left in place for 4 to 6 weeks to allow epithelialization of a tract.[2][6] Continuous pain or discomfort 24 hours after insertion indicates the bulb is too large. This can be easily corrected by withdrawing some of the fluid in the bulb.

    [Figure caption and citation for the preceding image starts]: Insertion of a Word catheter to treat a Bartholin’s cyst. The site is cleaned and anesthetized, and then a small stab incision (3 to 4 mm) is made into the cyst/abscess cavity (parallel to the hymen ring). The Word catheter is introduced into the cyst/abscess cavity after the contents have drained. The balloon is filled with sterile saline and a suture is tied around the catheter to prevent leaking or deflation. The catheter end is then tucked into the vagina.From the personal collection of Colleen Kennedy Stockdale; used with permission [Citation ends].com.bmj.content.model.Caption@9b04c73

  • One study looked at quality of life and sexual activity of 30 women with Bartholin cyst or abscess during treatment with a Word catheter, and found discomfort and pain during sexual activity decreased significantly from initial presentation to end of treatment.[33] While this is currently the only study to address quality of life and sexual activity during treatment of Bartholin cyst, the findings are limited by the methodology, including lack of a control group.

    Another trial reported similar recurrence rates among women with Bartholin gland abscess or recurrent cyst who were randomized to treatment with a Word catheter or marsupialization (12% vs. 10%, respectively within 1 year of treatment, P = 0.70).[34] Treatment with a Word catheter was associated with less pain during the 24-hour postprocedural period, and reduced time from diagnosis to intervention.[34]

  • A Jacobi ring catheter creates 2 drainage tracts rather than 1 and is thought to be as effective as a Word catheter.[35] A similar technique has been described using a small ring catheter made from butterfly Vacutainer tubing. A piece of Vicryl suture is threaded through the lumen, and the tubing is pulled through 2 small stab incisions in the cyst cavity and tied to create a loop.[32]

Excision

  • Excision of the cyst duct or gland was standard primary treatment of a Bartholin cyst until the late 1960s.[1] It is no longer the preferred treatment for primary surgery but may be required for recurrent cysts. Despite this, a 2019 observational study in French university hospitals found that gland excision was the most commonly used treatment for Bartholin cysts (68.5%), followed by marsupialization (22.5%).[9] The absence of a Bartholin gland may lead to dryness of the vulva, with severe itching, burning, and dyspareunia.[10][19][26][36]

  • Excision should be performed by an experienced gynecologic surgeon under general anesthesia because of the possibility of excessive bleeding from the underlying venous plexus.[1][12][16][19] Excision can be difficult if multiple previous attempts have been made to drain a cyst or abscess, and adhesions have formed. It should not be attempted in the presence of active infection.[12] Liquid paraffin may aid dissection.[16]

  • Complications of excision include hemorrhage, hematoma formation, cellulitis, sepsis, damage to the rectum, cosmetic disfigurement, and formation of scar tissue.[12][16][19][22]

Silver nitrate cauterization

  • Silver nitrate is a simple, cost-effective germicide and a chemical sclerosing agent. Its use has been described in the outpatient treatment of both cysts and abscesses.[12][37] Benefits of silver nitrate application include low rate of early and late morbidity, low recurrence rate, and avoiding sutures.[37] A prospective randomized controlled trial found that using silver nitrate and marsupialization were equally effective, with less scar formation noted with the use of silver nitrate.[38] Complications include chemical burns of the labial or surrounding mucosa, labial edema, hemorrhagic or purulent discharge, and cyst recurrence.[12]

Alcohol sclerotherapy

  • Compared with aspiration, instillation of alcohol for sclerotherapy reduced treatment time, with a low recurrence rate.[21] Complete evacuation of the injected alcohol is essential to avoid necrosis of the cyst wall. Compared with silver nitrate, alcohol sclerotherapy was as effective, with fewer complications and a faster healing time. There were no recurrences at 24-month follow-up.

Bartholin abscess

If an abscess points and ruptures spontaneously, conservative management with regular sitz baths, broad-spectrum antibiotics, and analgesia is usually all that is required.[19] Small abscesses can be treated with local application of warm, wet dressings or regular sitz baths. This promotes spontaneous drainage of the abscess or development to a stage suitable for incision and drainage.[6][19] Abscess recurs after incision and drainage in up to 15% of cases. Occasionally, early treatment of infection with broad-spectrum antibiotics prevents abscess formation. One 2019 observational study in French university hospitals found that incision and drainage was the most commonly used treatment for Bartholin abscesses (87%), followed by marsupialization (13%).[9]

After drainage (either spontaneous or surgical), broad-spectrum antibiotic coverage is recommended, and a catheter may be considered. Packing the cavity or leaving a catheter in situ allows a drainage tract to form and may reduce the risk of recurrence.[32] Definitive surgical methods are preferably deferred until active infection and inflammation have resolved. There is a lack of evidence to support a particular management strategy, and abscesses may recur.[24]

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