What is the treatment for a Bartholin cyst?

Management of Bartholin Cysts

The primary treatment for a symptomatic Bartholin cyst or abscess is drainage with placement of a Word catheter or marsupialisation, as both procedures have comparable recurrence rates of approximately 10-12% 1.

Diagnosis and Assessment

• Bartholin glands are located in the posterior vestibule at the 4 and 8 o'clock positions 2
• When infected, they present with swelling, erythema, and tenderness that can extend into the entire labia minora 2
• Ultrasound can help differentiate between simple, complicated, and complex cysts 3
• Signs of infection include a painful, tender, fluctuant red nodule with surrounding erythematous swelling 3

Treatment Options

Asymptomatic Cysts

• Small, asymptomatic Bartholin cysts that are not infected may resolve spontaneously without intervention 4
• Observation is appropriate for cysts that are not causing discomfort

Symptomatic or Infected Cysts (>2cm)

1. Word Catheter Placement:

   • Involves creating a small incision and placing a catheter with an inflatable balloon tip
   • Should remain in place for 4-6 weeks to allow epithelialization of the drainage tract
   • Advantages: Can be performed in office setting, shorter procedure time (approximately 1 hour from diagnosis to treatment) 1
   • Lower analgesic use in first 24 hours after treatment (33% vs 74% for marsupialisation) 1

2. Marsupialisation:

   • Creates a permanent opening by suturing the cyst wall to the surrounding tissue
   • Advantages: May be more definitive for recurrent cysts
   • Disadvantages: Longer procedure time (approximately 4 hours from diagnosis to treatment), higher analgesic use 1

3. Alternative Techniques:

   • Silver nitrate application 5
   • Alcohol sclerotherapy 6
   • Placement of small loop of plastic tubing as an alternative when Word catheter is unavailable 7

Recurrent Cysts

• Marsupialisation is often reserved for recurrent cases 6
• Complete surgical excision may be considered for multiple recurrences

Antibiotic Considerations

• Systemic antibiotics are rarely necessary for uncomplicated Bartholin cysts or abscesses 3
• Consider antibiotics in cases with:
  • Extensive surrounding cellulitis
  • Systemic manifestations
  • Immunocompromised patients
  • Multiple lesions

Post-Procedure Care

• The wound should be covered with a dry dressing 3
• Avoid frequent dressing changes to prevent cross-infection 3
• Follow-up to ensure proper healing and assess for recurrence
• Complete excision of the cyst wall may be considered once infection resolves to prevent recurrence 3

Special Considerations

• Bartholin gland cysts in women over 40 years should be evaluated carefully to rule out malignancy, as Bartholin gland carcinoma, while rare, is more common in this age group 5
• In cases of severe infection with risk of sepsis or rectovaginal fistula, more aggressive management may be required 6

Clinical Pearls

• Simple incision and drainage alone has an unacceptably high recurrence rate and should not be used as definitive treatment 6
• The choice between Word catheter and marsupialisation can be based on available resources and clinician expertise, as outcomes are comparable 1
• For patients with recurrent cysts, consider more definitive procedures like marsupialisation or complete excision