What is the treatment and dosing for a symptomatic Bartholin's cyst?

Treatment of Symptomatic Bartholin's Cyst

The preferred treatment for a symptomatic Bartholin's cyst is Word catheter placement, which should remain in place for 4-6 weeks to allow for epithelialization of a new drainage tract.

Diagnosis and Evaluation

• Bartholin's glands are located at the 4 and 8 o'clock positions at the vaginal introitus
• Symptomatic cysts typically present with:
  • Vulvar pain or discomfort
  • Dyspareunia
  • Difficulty with ambulation
  • Visible swelling at the vaginal introitus
• Abscesses additionally present with:
  • Erythema
  • Tenderness
  • Fluctuance
  • Purulent discharge

Treatment Options

First-line Treatment: Word Catheter Placement

1. Administer local anesthesia (1% lidocaine) at the planned incision site
2. Make a small (5-10 mm) incision on the mucosal surface of the cyst
3. Drain the cyst contents
4. Insert the Word catheter and inflate the balloon with 2-3 mL of water or saline
5. Leave the catheter in place for 4-6 weeks to allow epithelialization
6. Consider antibiotics only if abscess is present

Alternative Treatments (if Word catheter unavailable)

1. Marsupialization:

   • Make a larger incision (1.5-3 cm)
   • Suture the cyst wall to the surrounding tissue with absorbable sutures
   • Success rate comparable to Word catheter 1

2. Silver Nitrate Application:

   • After incision and drainage, apply silver nitrate to the cyst cavity
   • Similar recurrence rates to marsupialization 1

3. Improvised Catheter:

   • Small loop of plastic tubing can be used if Word catheter unavailable 2
   • Secure to prevent expulsion before epithelialization

4. Surgical Excision:

   • Reserved for recurrent cases or when malignancy is suspected
   • Higher complication rates (bleeding, scarring)
   • Not recommended as first-line treatment

Antibiotic Therapy

• Not routinely indicated for uncomplicated cysts
• For abscesses, consider empiric coverage for mixed aerobic/anaerobic flora:
  • Amoxicillin-clavulanate 875/125 mg PO BID for 7 days, OR
  • Cephalexin 500 mg PO QID plus metronidazole 500 mg PO BID for 7 days

Special Considerations

• Recurrent cysts: Consider marsupialization or surgical excision after multiple recurrences
• Pregnancy: Word catheter placement is safe during pregnancy
• Postmenopausal women: Higher risk of malignancy; consider biopsy if presentation is atypical

Follow-up

• Follow up in 1-2 weeks to ensure proper healing
• If using Word catheter, patient should return for removal after 4-6 weeks
• Instruct patient to return sooner if signs of infection develop (increasing pain, fever, purulent discharge)

Pitfalls and Caveats

• Failure to leave Word catheter in place for adequate time (4-6 weeks) increases recurrence risk
• Incision and drainage alone without catheter placement has high recurrence rates
• In women >40 years with new-onset Bartholin's cyst/abscess, consider biopsy to rule out adenocarcinoma
• Avoid incision at the hymenal ring to prevent excessive bleeding

The evidence suggests no single surgical intervention is definitively superior 1, but Word catheter placement offers the best balance of effectiveness, simplicity, and low recurrence rates for most patients with symptomatic Bartholin's cysts.