What are the treatment options for Bartholin cysts?

Treatment of Bartholin Cysts

For symptomatic Bartholin cysts or abscesses larger than 2 cm, perform fistulization (Word catheter placement) or marsupialization as first-line treatment, as these have the lowest recurrence rates and can be performed in the office setting. 1, 2, 3

Initial Assessment and Triage

Asymptomatic cysts:

• Small, asymptomatic Bartholin duct cysts often resolve spontaneously without intervention and can be managed expectantly 1
• No treatment is required unless the cyst becomes symptomatic or infected 1

Symptomatic cysts or abscesses:

• Cysts or abscesses larger than 2 cm should be drained, as they do not tend to resolve spontaneously and frequently recur without intervention 1
• Diagnosis is primarily clinical, based on physical examination showing a tender, fluctuant mass at the vaginal introitus at the 4 or 8 o'clock position 4
• Assess for signs of cellulitis (erythema, warmth, spreading inflammation), systemic infection (fever, malaise), or extensive inflammation extending into the labia minora 4

Antibiotic Therapy Indications

Antibiotics are indicated only when:

• Signs of cellulitis are present (erythema extending beyond the cyst margin) 4, 5
• Systemic infection is evident (fever, chills, malaise) 4, 5

Antibiotic regimens when indicated:

• Metronidazole, Ciprofloxacin, Levofloxacin, or Ceftriaxone are appropriate options for perineal infections 4
• Consider coverage for sexually transmitted infections (gonorrhea and chlamydia) as these can infect Bartholin glands 4

Surgical Management Options (Ranked by Recurrence Rate)

Preferred office-based procedures (lowest recurrence):

1. Marsupialization - Creates a permanent opening by suturing the cyst lining to the vestibular skin 2, 3

   • Zero recurrence rate reported in available studies 2
   • Healing typically occurs within 2 weeks 2
   • Can be performed in office setting 3

2. Fistulization with Word catheter - Small inflatable catheter left in place for 4-6 weeks 2, 3

   • Low recurrence rate (varies by study but generally <10%) 2
   • Healing and recurrence rates similar to marsupialization 3
   • Simplest definitive procedure for office management 6
   • Caveat: Catheter may dislodge before epithelialization is complete, leading to recurrence 6
   • Alternative: Loop of plastic tubing can be used when Word catheter unavailable 6

3. Silver nitrate ablation or alcohol sclerotherapy 2, 3

   • Healing and recurrence rates similar to marsupialization and fistulization 3
   • Less commonly performed but effective option 2

Procedures NOT recommended due to high recurrence:

• Simple needle aspiration - High recurrence rate, not recommended as definitive treatment 2, 3
• Incision and drainage alone - High recurrence rate, not recommended as definitive treatment 2, 3

Surgical excision:

• Reserved for recurrent cysts after multiple failed conservative treatments 7, 2
• Requires general anesthesia and has higher morbidity 7
• Not first-line due to complexity and bleeding risk 7

Treatment Algorithm

Step 1: Determine if cyst is symptomatic and size

• If asymptomatic and small: Expectant management 1
• If symptomatic or >2 cm: Proceed to Step 2

Step 2: Assess for infection complications

• If cellulitis or systemic infection present: Add antibiotics (Metronidazole, Ciprofloxacin, Levofloxacin, or Ceftriaxone) 4
• Proceed to Step 3 regardless

Step 3: Perform definitive drainage procedure

• First choice: Marsupialization (if trained) or Word catheter placement 2, 3
• Avoid simple incision and drainage or needle aspiration alone 3

Step 4: Follow-up

• Reassess at 3 weeks to ensure healing 6
• If recurrence occurs: Consider marsupialization if Word catheter was initially used, or surgical excision for multiple recurrences 7, 2

Common Pitfalls

• Avoid simple incision and drainage or needle aspiration as definitive treatment - these have the highest recurrence rates and should only be used for temporary relief if definitive procedures cannot be performed immediately 2, 3
• Do not prescribe antibiotics routinely - they are only indicated when cellulitis or systemic infection is present, not for uncomplicated cysts or abscesses 4, 5
• Ensure Word catheter remains in place for adequate time (4-6 weeks) to allow complete epithelialization of the drainage tract 6