Treatment of Bartholin Cysts
Bartholin cysts that are asymptomatic and less than 2 cm can be managed expectantly, while symptomatic or infected cysts larger than 2 cm should be drained using either Word catheter placement or marsupialisation, as both methods have comparable recurrence rates of approximately 10-12%.
Diagnosis and Classification
Bartholin glands are located at the posterior portion of the vaginal opening. When the ducts become obstructed, they can form:
- Simple cysts: Painless, fluid-filled sacs
- Abscesses: Infected cysts that are painful, tender, and may contain purulent material
Management Algorithm
1. Asymptomatic Cysts
- If less than 2 cm: Expectant management with no intervention required 1
- If larger than 2 cm: Consider elective drainage to prevent future infection
2. Symptomatic Cysts or Abscesses
- First-line treatment options (comparable effectiveness):
- Word catheter placement: A small balloon catheter inserted into the cyst after incision
- Marsupialisation: Surgical creation of a pouch by suturing the cyst walls to surrounding tissue
Both treatments have similar recurrence rates (Word catheter 12% vs. marsupialisation 10%), but Word catheter placement has significant advantages 2:
- Shorter procedure time (1 hour vs. 4 hours)
- Less post-procedure analgesic use (33% vs. 74%)
- Can be performed in office setting
3. Alternative Techniques
- Improvised catheter: When Word catheter is unavailable, a loop of plastic tubing can be used 3
- Silver nitrate application: Less commonly used
- CO2 laser: For specialized settings
- Surgical excision: Reserved for recurrent cases or when malignancy is suspected
Antibiotic Therapy
For abscesses, empiric antibiotic therapy may be considered alongside drainage:
- Most infections are polymicrobial with coliforms being most common 4
- Broad-spectrum antibiotics like co-amoxiclav are appropriate when antibiotics are indicated
- STI testing should be performed, though N. gonorrhoeae and C. trachomatis are uncommon causes
Clinical Pearls and Pitfalls
- Important distinction: Differentiate between simple cysts (which may resolve spontaneously) and abscesses (which require drainage)
- Recurrence risk: Approximately 10-12% regardless of treatment method
- Word catheter retention: Should remain in place for 4-6 weeks to allow epithelialization of the tract
- Malignancy consideration: In women over 40 with atypical presentation or recurrent cysts, consider biopsy to rule out adenocarcinoma
Follow-up
- Follow-up examination 2-3 weeks after procedure
- Removal of Word catheter after 4-6 weeks
- Patient education regarding potential recurrence
The evidence clearly shows that both Word catheter placement and marsupialisation are equally effective for treating symptomatic Bartholin cysts and abscesses, with Word catheter offering advantages in terms of procedure time and post-procedure comfort 2.