Treatment of Bartholin Cyst
For symptomatic Bartholin cysts or abscesses, surgical drainage is the primary treatment, with Word catheter placement and marsupialization being equally effective first-line options, while antibiotics should be reserved only for cases with surrounding cellulitis or systemic infection. 1, 2
Initial Assessment and Diagnosis
- Diagnosis is clinical, based on physical examination showing a tender, fluctuant mass at the 4 or 8 o'clock position of the vaginal introitus 2
- Evaluate for complications: Look specifically for signs of cellulitis (spreading erythema, warmth), systemic infection (fever, malaise), or extensive inflammation extending into the labia minora 2
- Asymptomatic cysts <2 cm can be managed expectantly as they often resolve spontaneously without intervention 3
Treatment Algorithm
For Asymptomatic or Small Cysts (<2 cm)
- Expectant management with comfort measures is appropriate, as these typically resolve without intervention 3
For Symptomatic Cysts or Abscesses (≥2 cm)
Surgical drainage is required because these do not resolve spontaneously and will recur without intervention 3
Primary surgical options (choose either):
Word catheter placement: Simple office procedure using readily available materials, takes approximately 1 hour from diagnosis to treatment, catheter remains in place for 4-6 weeks to allow epithelialization 4, 5
Marsupialization: Takes approximately 4 hours from diagnosis to treatment, creates a permanent drainage opening 5
Both methods have equivalent recurrence rates (12% for Word catheter vs 10% for marsupialization, not statistically different), so choice depends on available resources and clinical setting 5
Alternative Techniques
- Loop drainage technique using plastic tubing can be employed when Word catheter is unavailable, using readily available ED materials 4
- Silver nitrate application or CO2 laser cauterization are additional options for recurrent cases 6
Antibiotic Therapy - Use Selectively
Antibiotics are NOT routinely indicated for simple drainage procedures 1, 2
Prescribe antibiotics ONLY when:
- Signs of cellulitis are present (spreading erythema beyond the cyst)
- Systemic infection is evident (fever, sepsis)
- Extensive surrounding inflammation exists 1, 2
Antibiotic choices for perineal infections when indicated:
- Metronidazole
- Ciprofloxacin
- Levofloxacin
- Ceftriaxone 2
Note on microbiology: Bartholin abscesses are typically caused by opportunistic polymicrobial infections with coliforms being most common; sexually transmitted organisms (gonorrhea, chlamydia) are rarely isolated 7
Post-Procedure Management
- Analgesic use: 33% of Word catheter patients require analgesics in first 24 hours versus 74% of marsupialization patients 5
- Follow-up at 3 weeks to assess healing and remove drainage device 4
- Recurrence occurs in approximately 10-12% of cases regardless of initial surgical method chosen 5
Common Pitfalls to Avoid
- Do not prescribe antibiotics routinely - they are unnecessary for uncomplicated drainage and contribute to resistance 1, 2
- Do not attempt drainage of cysts <2 cm unless highly symptomatic, as expectant management is appropriate 3
- Ensure Word catheter remains in place 4-6 weeks - premature dislodgement before epithelialization leads to recurrence 4