What are the management options for a Bartholin cyst?

Management of Bartholin Cyst

The management of Bartholin cysts should follow a stepwise approach, with Word catheter placement being the first-line treatment for symptomatic cysts or abscesses due to its comparable efficacy to marsupialisation with less pain and shorter procedure time. 1

Understanding Bartholin Cysts

• Bartholin gland cysts affect approximately 2% of women 2, 3
• Asymptomatic cysts smaller than 2 cm often resolve spontaneously without intervention 4
• Symptomatic cysts or abscesses larger than 2 cm typically require drainage as they rarely resolve on their own and tend to recur 4

Management Options

1. Expectant Management

• Appropriate for asymptomatic, small (<2 cm) cysts
• May include warm sitz baths and comfort measures
• No surgical intervention required

2. Symptomatic Cysts or Abscesses (>2 cm)

First-Line Treatment: Word Catheter

• Procedure:
  • Local anesthetic administration
  • Incision and drainage of the cyst/abscess
  • Placement of Word catheter
  • Catheter remains in place for approximately 4 weeks to allow epithelialization of the tract 2
• Advantages:
  • Can be performed in office or emergency department setting
  • Less painful than marsupialisation (only 33% require analgesics post-procedure vs. 74% for marsupialisation) 1
  • Shorter procedure time (1 hour from diagnosis to treatment vs. 4 hours for marsupialisation) 1
  • High success rate (97% resolution in one study) 2
• Potential issues:
  • Catheter may dislodge before epithelialization (23% dislodgement rate) 2

Alternative: Improvised Catheter

• When Word catheter is unavailable, a loop of plastic tubing can be used as an alternative 5
• The tubing is secured to prevent expulsion before epithelialization occurs

Second-Line Treatment: Marsupialisation

• Procedure:
  • Creation of a permanent opening in the cyst wall
  • Edges of the cyst wall are sutured to surrounding tissue
• Comparable recurrence rate to Word catheter (10% vs. 12%) 1
• Disadvantages:
  • More painful (74% require analgesics post-procedure)
  • Longer procedure time (4 hours from diagnosis to treatment)
  • May require general anesthesia

Other Surgical Options

• Silver nitrate application
• Carbon dioxide laser
• Surgical excision (for recurrent cases or when malignancy is suspected)

Follow-up and Recurrence

• Recurrence rates are similar between Word catheter and marsupialisation (12% vs. 10%) 1
• Most women (89%) who had Word catheter treatment would choose the same treatment if recurrence occurred 2
• Sexual intercourse can be resumed within 2 weeks of Word catheter placement without significant discomfort 2

Special Considerations

• In women over 40 years, especially with recurrent cysts, consider biopsy to rule out malignancy
• For severe or recurrent infections not responding to standard treatments, referral to a specialist may be necessary 4

Treatment Algorithm

1. Assess cyst size and symptoms:

   • Asymptomatic, <2 cm: Expectant management
   • Symptomatic or >2 cm: Proceed to drainage

2. For symptomatic cysts/abscesses:

   • First-line: Word catheter placement under local anesthesia
   • If Word catheter unavailable: Consider improvised catheter technique
   • If Word catheter fails or is contraindicated: Consider marsupialisation

3. For recurrent cysts after multiple drainage attempts:

   • Consider definitive surgical excision
   • Rule out malignancy in women >40 years