What is the treatment for vulvar cysts?

Treatment for Vulvar Cysts

For benign vulvar cysts, observation is appropriate for asymptomatic lesions, while symptomatic cysts require surgical excision with complete removal to prevent recurrence. 1, 2

Initial Assessment and Diagnosis

The first priority is distinguishing benign cysts from malignant lesions, particularly in women over 40 years of age. 2 Key diagnostic steps include:

• Biopsy is mandatory for any irregular, nodular vulvar mass in menopausal or perimenopausal women to rule out adenocarcinoma. 1
• Document the cyst's characteristics: size, location, mobility (fixed lesions raise concern), and associated symptoms (pain or bleeding warrant heightened suspicion). 2
• Imaging with transvaginal ultrasound or MRI is indicated for large cysts or those with uncertain depth of extension into perineal tissue. 3, 2

Management Algorithm by Clinical Presentation

Asymptomatic Benign Cysts

• Observation without intervention is the recommended approach for asymptomatic vulvar cysts that are clearly benign on examination. 4, 2
• These cysts typically grow slowly and rarely cause complications. 5

Symptomatic Benign Cysts

Surgical excision is the definitive treatment when cysts cause pain, irritation, or functional impairment. 1, 5, 4, 3, 2

Surgical options include:

• Complete excision is preferred to prevent recurrence and allow full pathologic examination. 4, 3, 2
• Alternative techniques for smaller lesions include pinch-punch excision or incision and drainage, though these have higher recurrence rates. 5
• Heat application has been described but is not standard practice. 5

Bartholin's Duct Cysts and Abscesses (Specific Subtype)

These require distinct management:

• Word catheter insertion is appropriate for both Bartholin's duct cysts and gland abscesses as an office-based procedure. 1
• Marsupialization is indicated for Bartholin's duct cysts but should NOT be used for gland abscesses. 1
• Broad-spectrum antibiotics are warranted only when cellulitis is present, not routinely. 1

Critical Surgical Considerations

• Complete surgical removal with pathologic examination is essential to confirm diagnosis and rule out malignancy. 4, 3
• For giant cysts (>10 cm), MRI is particularly valuable for surgical planning to assess extension into deep perineal structures. 3
• Post-operative complications can include hematoma formation, which typically resolves with conservative management. 4
• Long-term surveillance is recommended after excision to monitor for recurrence. 4

Common Pitfalls to Avoid

• Do not assume all vulvar masses are benign cysts in older women—always consider malignancy and obtain tissue diagnosis when indicated. 1, 2
• Do not use marsupialization for Bartholin's gland abscesses—this is only appropriate for duct cysts. 1
• Do not prescribe antibiotics routinely for Bartholin's cysts or abscesses unless cellulitis is present. 1
• Do not leave symptomatic cysts untreated—surgical excision has high success rates and prevents ongoing morbidity. 2

Special Populations

• Adolescent girls with vulvar cysts are uncommon, and epidermoid cysts should be considered; trauma and surgical interventions are typical etiologies. 3
• Women over 40 years require heightened vigilance with any vulvar mass, particularly those that are fixed, painful, or bleeding. 2