Bartholin Cyst: Diagnosis and Management
A Bartholin cyst is a fluid-filled swelling that develops when the duct of the Bartholin gland becomes obstructed, leading to fluid accumulation and potential infection. These cysts are among the most common gynecologic problems, affecting approximately 2% of women 1.
Anatomy and Pathophysiology
- The Bartholin glands are located bilaterally at the posterior introitus (at the 4 o'clock and 8 o'clock positions) and drain through ducts that empty into the vestibule 2
- These normally pea-sized glands are only palpable if the duct becomes cystic or a gland abscess develops 2
- Obstruction of the Bartholin duct can lead to fluid retention and cyst formation 3
- When infected, these cysts can develop into abscesses, presenting with swelling, erythema, and tenderness that can extend into the entire labia minora 4
Clinical Presentation
- Many Bartholin cysts remain asymptomatic and resolve spontaneously without intervention 3
- Symptomatic cysts may cause discomfort during walking, sitting, or sexual activity 1
- Infected cysts (abscesses) typically present with pain, swelling, erythema, and sometimes purulent discharge 2
- On examination, a Bartholin cyst appears as a unilateral swelling at the posterior introitus 4
Differential Diagnosis
The differential diagnosis includes:
- Epidermal inclusion cyst 2
- Skene's duct cyst 2
- Hidradenoma papilliferum 2
- Lipoma 2
- In postmenopausal women, adenocarcinoma should be considered 2
Diagnostic Approach
- Diagnosis is primarily clinical, based on the characteristic location and appearance of the cyst 2
- Although any vaginal organism can infect the glands, they are commonly infected by STI pathogens, including gonorrhea and chlamydia 4
- In menopausal or perimenopausal women with an irregular, nodular Bartholin's gland mass, excisional biopsy should be performed to rule out adenocarcinoma 2
Management Options
Infected Bartholin duct cysts or glandular abscesses larger than 2 cm should be drained as they do not tend to resolve spontaneously and can recur. 3
1. Expectant Management
- Appropriate for asymptomatic, non-infected cysts 3
- Comfort measures such as sitz baths and analgesics may be recommended 3
2. Medical Management
- Antibiotics are warranted only when cellulitis is present 2
- For abscesses, broad-spectrum antibiotics may be considered while awaiting culture results 5
- Common pathogens include coliform bacteria and other opportunistic organisms, often as polymicrobial infections 5
3. Surgical Management
- Word catheter insertion: Office-based procedure for duct cysts or gland abscesses 2
- Marsupialization: Appropriate for cysts but not for gland abscesses 2
- Alcohol sclerotherapy: Destroys the epithelial covering of the cyst through coagulative necrosis and fibrosis, preventing fluid reformation 6
- Excisional biopsy: Reserved for ruling out adenocarcinoma in menopausal or perimenopausal women 2
Special Considerations
- The goal of management is to preserve the gland and its function when possible 2
- Recurrent cysts may require more definitive surgical intervention 1
- Alcohol sclerotherapy has shown promising results with low recurrence rates 6
- Whether adjuvant antibiotic therapy is necessary following surgical treatment remains controversial 5