What are the symptoms and treatment options for Bartholin's adenitis?

Bartholin's Adenitis: Symptoms and Treatment

Symptoms

Bartholin's adenitis presents with a tender, swollen, erythematous mass at the posterior vaginal introitus, typically at the 4 or 8 o'clock positions, with tenderness that may extend into the labia minora. 1

Key clinical features include:

• Fluctuant, painful mass at the vaginal opening that is palpable on examination 2
• Swelling and erythema localized to one side (right side in 48.4% of cases, left side in 51.6%) 3
• Tenderness that can extend into surrounding labial tissue 1
• Signs of cellulitis in more severe cases, including spreading erythema and warmth 1, 2
• Systemic symptoms such as fever may indicate more extensive infection 1

The diagnosis is primarily clinical based on physical examination findings of a tender, fluctuant mass at the vaginal introitus 1.

Treatment Approach

Surgical Management (Primary Treatment)

The goal of treatment is to preserve gland function through drainage procedures, not excision. 2

For initial presentation, incision and drainage with Word catheter placement is the standard office-based procedure. 2, 4 However, treatment selection should be based on whether this is a first presentation or recurrence:

First-Line Surgical Options:

• Incision and drainage with silver nitrate application shows the lowest recurrence rate (9.1%) and should be preferred over simple incision and drainage 3
• Word catheter insertion for both cysts and abscesses, performed as an office procedure 2, 4
• Marsupialization is appropriate for cysts but should NOT be used for active abscesses 2

For Recurrent Cases:

• Marsupialization or incision with silver nitrate are effective in over 90% of recurrent cases 3
• Simple incision and drainage has only 30% effectiveness in recurrent disease and should be avoided 3

Antibiotic Therapy

Antibiotics are indicated only when there are signs of cellulitis or systemic infection, not for routine uncomplicated abscesses treated surgically. 1, 2

When antibiotics are warranted:

• Recommended regimens include Metronidazole, Ciprofloxacin, Levofloxacin, or Ceftriaxone for perineal infections with cellulitis 1
• Broad-spectrum coverage such as co-amoxiclav may be suitable for empirical treatment given the polymicrobial nature of these infections 5
• Duration: 5-7 days is typically sufficient when combined with surgical drainage 6

Important Microbiology Considerations

The microbiology differs from traditional teaching:

• Opportunistic organisms (particularly coliforms) are the most common pathogens, either as single agents or polymicrobial infections 5
• Aerobic organisms predominate, with coliforms being most frequent 5
• Gonorrhea and chlamydia are rarely isolated despite being historically emphasized 5
• Respiratory pathogens including penicillin-resistant Streptococcus pneumoniae and beta-lactamase-nonproducing ampicillin-resistant Haemophilus influenzae have been documented, requiring consideration of drug-resistant bacteria 6

Critical Pitfalls to Avoid

• Do not perform marsupialization on an active abscess—this is reserved for cysts only 2
• Do not routinely prescribe antibiotics for uncomplicated abscesses that receive adequate surgical drainage 2
• Do not use simple incision and drainage alone for recurrent cases, as this has a 39.6% recurrence rate 3
• In menopausal or perimenopausal women with irregular, nodular Bartholin's masses, excisional biopsy is necessary to rule out adenocarcinoma 2