What is the treatment for a Bartholin cyst?

Treatment of Bartholin Cysts

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

Anatomy and Presentation

• Bartholin glands are located in the posterior vestibule at the 4 and 8 o'clock positions
• When infected, they present with swelling, erythema, and tenderness that can extend into the labia minora
• Asymptomatic cysts smaller than 2 cm may resolve spontaneously without intervention 2

Treatment Algorithm

First-line options (equivalent effectiveness):

1. Word Catheter Placement

   • Create a small incision and place a catheter with an inflatable balloon tip
   • Keep in place for 4-6 weeks to allow epithelialization of the drainage tract
   • Advantages:
     • Shorter procedure time (1 hour vs 4 hours for marsupialisation) 3
     • Lower analgesic use (33% vs 74% in first 24 hours) 3
     • Can be performed in office/ED setting

2. Marsupialisation

   • Creates a permanent opening by suturing the cyst wall to surrounding tissue
   • Advantages:
     • More definitive for recurrent cysts 1
   • Disadvantages:
     • Longer procedure time
     • Higher analgesic requirements
     • Often requires surgical setting

Alternative options:

1. Novel techniques

   • Loop of plastic tubing as an alternative when Word catheter unavailable 4
   • Silver nitrate application or alcohol sclerotherapy 5

2. Complete excision

   • Consider for recurrent cases
   • Recommended for women over 40 to rule out malignancy 1
   • Should be performed after any infection resolves

Management considerations

• For infected cysts/abscesses:

  • Systemic antibiotics may be considered with:
    • Extensive surrounding cellulitis
    • Systemic manifestations
    • Immunocompromised patients
    • Multiple lesions 1

• Post-procedure care:

  • Cover with dry dressing
  • Avoid frequent dressing changes to prevent cross-infection
  • Schedule follow-up to ensure proper healing and assess for recurrence

Clinical pearls and pitfalls

• Simple incision and drainage alone has an unacceptably high recurrence rate and is insufficient for primary treatment 5
• Ultrasound can help differentiate between simple, complicated, and complex cysts 1
• More aggressive management may be required in cases with risk of sepsis or rectovaginal fistula 5
• The recurrence rate is similar between Word catheter and marsupialisation (12% vs 10%) based on randomized controlled trial data 3
• Gram stain and culture are not routinely recommended but may be considered for unusual presentations or treatment failures 1

While both Word catheter and marsupialisation are equally effective in terms of recurrence rates, the Word catheter offers advantages of shorter procedure time and less post-procedure pain medication use, making it an excellent first-line option for most patients.